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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with BPAD on lithium, h/o cocaine abuse, HTN, HLD and DM sent in from ___ on ___ for increased confusion and altered mental status, worse this AM. She was admitted to ___ on ___ with depression and agitation. She was started on lithium a week prior to admission and had a level checked on ___ which was 1.3. Her Cr prior to admission was 0.8. After a week on lithium, she was noted to be "slowed down" per nursing staff. A level was checked on ___ which was She was found to have a lithium level of 2.4 on ___. Last FSBG was 70. She also complains of decreased appetite and a hand tremor that began today. In the ED, initial vitals were: T:96.8 HR 67 BP: 96/65 RR 16 O2sat 100%. Labs were notable for an eosinophilia of 17%, Na 132 and Cr 1.3. Tox screen was negative. VBG was 7.36/47/39/28. On the floor, VS were 98.6, 94/82, 64, 18, 95%. Pt was awake, alert, oriented x3, tearful. Interviewed with help of ___ interpreter, speech was slurred. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Radiology showed Opacity in the superior segment of the right lower lobe could reflect atelectasis particularly given low lung volumes, however infection should be considered in the appropriate clinical setting. Consider repeat evaluation with improved inspiration when patient is able. The patient was diagnosed with UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE, RENAL & URETERAL DIS NOS, ADV EFF PSYCHOTROPIC NEC. At the time of discharge, the patient had Primary diagnosis: Lithium toxicity Secondary diagnoses: bipolar disorder, diabetes mellitus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with BPAD on lithium, h/o cocaine abuse, HTN, HLD and DM sent in from ___ on ___ for increased confusion and altered mental status, worse this AM. She was found to have a lithium level of 2.4 on ___. EKG showed sinus bradycardia with a rate of 60, LAD w/ ?LBBB, LVH and T wave inversions # Lithium toxicity: Likely increased level in setting of ___, particularly in a patient on lisinopril with questionable PO intake. She was aggressively hydrated with normal saline and her lithium level trended down, as did her creatinine. ___ was 1.3 on discharge. She was monitored on telemetry and with q4 neuro checks. # Non anion-gap metabolic acidosis: Likely due to increased NS. Stable at discharge, fluids were changed to LR. # Hyponatremia: Na 132 initially, increased to 136. Patient looks euvolemic to hypovolemic on exam. Improvement with fluids suggests hypovolemic hyponatremia as in ___ the sodium would decrease with IVF. Sodium was 137 on discharge. # Hypertension: Amlodipine was held in the setting of hypotension. Blood pressures remained stable and her amlodipine was continued on discharge. It is important that the patient remain well hydrated at all times with antihypertensives and lithium on board. # Diabetes: Hold glucophage in setting of renal dysfunction. She was maintained on insulin sliding scale while in the hospital. # COPD: continued triotropium, advair, albuterol</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o female with a history of HTN and HLD who presented with chest pain and presyncope this morning and was found to have STEMI. CHEST (PORTABLE AP) ___ showed Prior chest radiographs available. Heterogeneous opacification in the left lower lung is new. Most likely this is atelectasis but close follow-up is recommended for the possibility of aspiration and potential subsequent pneumonia. Upper lungs clear. Heart size normal. No mediastinal widening. No pneumothorax or pleural effusion. CT ABD AND PELVIS W/O CONTRAST showed 1. No evidence of retroperitoneal hemorrhage. The patient was diagnosed with ST elevation (STEMI) myocardial infarction of unsp site. The patient was treated with LHC with PCI. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o female who presented with chest pain and presyncope and was found to have STEMI. Course complicated by anemia and GI bleed with ulcerations in the esophagus, now stabilized. Patient also developed Afib/Atrial flutter now rate controlled with Digoxin and Metoprolol. # CORONARIES: DES x2 to RCA, 30% ___ LAD # PUMP: EF 47% # RHYTHM: Afib/Aflutter</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o RSD (reflex sympathetic dystrophy), HTN, GERD, IBS, asthma, PE with acute cor pulmonale and pulmonary fibrosis on 4 L of oxygen at home with chronic pain requiring a brain stimulator with recent bulbar symptoms causing her to become severely dysphasic requiring an outpatient eval for G-tube who presents for inability to tolerate p.o. for several days and was found to be hypotensive at her PCPs office. She states that she has had difficulty with swallowing for "awhile" now and was previously on a soft/pureed diet. Over the last week it has become increasingly difficult for her to swallow solids or liquids and as a result she has been unable to take many of her medications. She was recently seen by her pain doctor who was recommending a G-tube be placed so that she would be able to take enteral nutrition/medications again. The plan was initially to try and hold off until after ___ to have her come into the hospital but today in her PCPs office she was noted to be hypotensive and was sent to the ED. Patient notes that this morning she felt weak and "not like [herself]". She attributes this to not eating or drinking more than a intermittent sips for the past few days. Patient also notes that she had a fall recently due to lower extremity weakness which has exacerbated her chronic back pain. CHEST (PORTABLE AP) showed Multiple devices and wires project over the chest. Bibasilar atelectasis. Chest radiographs, two AP upright portable views. showed Dobhoff terminating in the stomach. Mostly resolved atelectasis at each lung base. Radiology showed There is a Dobhoff tube with distal tip in the fundus of the stomach. There are markedly low lung volumes. Atelectasis at the lung bases. There are no pneumothoraces. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___ through ___. Transesophageal feeding tube coiled appropriately in the upper stomach. Multiple indwelling stimulator leads unchanged in their respective positions. Lung volumes remain exceedingly small, exaggerating mild cardiomegaly. No definite pulmonary abnormality. Pleural effusions small if any. No pneumothorax. Radiology showed Successful placement of a 20 ___ Ponsky gastrostomy tube via pull technique. Radiology showed There is a percutaneous gastrostomy tube projecting over the left upper quadrant of the abdomen. There are no abnormally dilated loops of small or large bowel. No free intraperitoneal air is identified. No suspicious radiopaque calculi are visualized. The osseous structures are unremarkable. Spinal cord stimulator leads are noted in the lower thoracic and upper lumbar spine. The patient was diagnosed with Hypotension, unspecified. The patient was treated with PEG Tube (___). At the time of discharge, the patient had PRIMARY DIAGNOSIS ================== Oral pharyngeal and esophageal dysphasia Acute kidney injury hypotension SECONDARY DIAGNOSIS ===================== Urinary tract infection Chronic regional pain syndrome. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF HOSPITAL COURSE ===================== ___ with h/o thoracic outlet syndrome s/p rib resections in ___, subsequent chronic regional pain syndrome, HTN, GERD, IBS, asthma, PE with acute cor pulmonale on 4 L at home with chronic pain requiring a brain stimulator with recent bulbar symptoms leading to oral pharyngeal and esophageal dysphasia. The patient was noted to be hypotensive by ___ likely in the setting of poor p.o. intake over the last several weeks and was admitted to ___ for further workup. The patient could not tolerate a dobhoff so PEG was placed for supplemental enteral feeding. ============== Active Issues ============== #Decreased PO Intake #Oropharyngeal and esophageal dysphagia #Stuttering #Hypotension Patient had a recent admission to ___ for oropharyngeal and esophageal dysphasia and worsening shortness of breath in the setting of possible diaphragmatic weakness. Her symptoms were developing over the last several months and had been evaluated by her outpatient neurologist and workup has so far included normal CK, TSK, myositis panel, alpha glucosidase activity. During the admission to ___, her workup included an EMG which showed decreased recruitment in genioglossus and VSS study showing oropharyngeal and esophageal dysmotility with silent aspiration. Etiology of these symptoms was not determined, there was a concern for functional component. She was discharged with follow-up with the neuromuscular specialist. Her motor cortex stimulator was turned off in the last 3 weeks, but this does not appear to significantly improve her symptoms. Over the last few weeks her dysphasia continued to worsen and she was unable to tolerate p.o. intake. She has close follow-up with ___ and speech therapy as an outpatient and was noticed to be hypotensive which resulted in her admission to ___ ___. ___ was fluid resuscitated which improved her ___ and hypotension. Her hypotension was likely caused by poor p.o. intake given no signs for infection, cardiogenic or obstructive cause. Her antihypertensives were held: Lisinopril 40mg daily, Metoprolol Succ 100mg Daily, Lasix 20mg daily, Amlodipine 7.5mg daily. Neurology was consulted and felt that her CRPS may be contributing to her dysphagia. Dobbhoff was placed and tube feeds were started to supplement nutrition, but the patient could not tolerate the tube d/t gagging sensation particularly with medications. A PEG was placed on ___ and we were working on scheduling with outpatient follow up with neurology with continued outpatient ___ and Speech therapy. #Hypoxia #Restrictive lung disease likely ___ diaphragmatic paralysis #History of unprovoked pulmonary embolism Patient w/ known PE and bronchiectasis and concern for diaphragmatic paralysis. Currently uses ___ O2 at home but was discharged on 1L NC from ___ 1 month ago. Currently feels her breathing is at her baseline. She was on Xarelto at home for anticoagulation. She was started on heparin drip while inpatient given lack of enteral access and after Dobbhoff was placed was started on apixaban twice daily given possibility of Dobbhoff migrating into the jejunum which would limit absorption of rivaroxaban. A PEG was ultimately placed and she continued on apixaban 5mg BID. She was continued on Advair daily. #Anemia Hgb 10.7 in ED with recent baseline around ___ per ___ records. No active signs of bleeding. Her hemoglobin was stable during admission. #UTI UA in ED concerning for infection w/ large leuk esterase, 49 WBCs, few bacteria. Urine culture grew pansensitive E. coli. She was started on ceftriaxone in the ED and was narrowed to nitrofurantoin with sensitivities. She completed a 5-day course of antibiotics. ___ Presented with Cr of 1.3 from last known 0.7 in ___. Received 4L IVF and improved to 0.6. Likely in the setting of dehydration and poor p.o. intake. ============== Chronic Issues ============== #Hypertension -Her home antihypertensives were held initially lisinopril 40mg daily, Metoprolol Succ 100mg Daily, Lasix 20mg daily, Amlodipine 7.5mg daily. She remained normotensive during admission and was restarted on metoprolol succ 25mg XL at discharge. #Reflex Sympathetic Dystrophy #Chronic Pain Patient w/ significant chronic pain. Follows with Dr. ___ in Pain ___ here. He was initially started on IV Dilaudid given lack of enteral access and was transitioned to her home regimen of Dilaudid p.o. ___ mg 4 times daily as needed. -Continue Lyrica 300mg BID -Holding ketamine lozenges while inpatient</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with the past medical history notable for uncontrolled DM, HTN, pyoderma of right hip, recurrent necrotizing fasciitis of abdomen/groin s/p multiple debridements and now wound vac, who presents from her SNF with concerns for her care there. Radiology showed Percutaneous gastrojejunostomy catheter is looped in the stomach with tip in the region of the pylorus, as seen on the prior CT exam. No extraluminal oral contrast material seen. The patient was diagnosed with Diarrhea, unspecified. At the time of discharge, the patient had Hyperglycemia Recurrent necrotizing fasciitis Sacral uclers Gastroparesis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female with poorly controlled DM2, HTN, pyoderma of R hip, recurrent necrotizing fasciitis of abdomen/groins/p multiple debridement presenting from rehab with hyperglycemia and awaiting insurance auth to be transferred to a different facility. # Hyperglycemia, uncontrolled DM - baseline HgB 11% and has been affected by her recent infections and hospitalizations. She was restarted on glargine and regular insulin 7U (at 1200, 1800, and 0000) with TF's and ISS with regular insulin. FSBG's were in the high 100's to 200's. # Gastroparesis with TF dependence: pt continued on Glucerna </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with complicated medical comorbidities including CAD status post three-vessel CABG, along with systolic CHF with EF around 30%, with recent finding of kidney mass suspicious of RCC presenting for sudden onset dyspnea. Patient reports that he was home yesterday morning developed sudden onset dyspnea after breakfast. No chest pain or palpitations. Dyspnea worse with exertion. Rested for several hours but dyspnea persisted. Of note, he has a history of significant systolic CHF with an ejection fraction estimated around 30% or so, maintained on torsemide diuretic along with beta blockade and ___ therapy. He underwent a nuclear stress test with nuclear imaging on ___ which revealed left ventricular dilation at rest and during stress, with a global ejection fraction of ___ with diffuse hypokinesis with akinesis in the interventricular septum, inferior infarct without ischemia. An echo on ___ revealed LV enlargement with moderate systolic dysfunction with an EF of 35%, 2+ mitral insufficiency, 2+ tricuspid insufficiency, severe pulmonary hypertension and right ventricular systolic pressures of 60-65. In the ED, initial vitals were: Labs were significant for BNP of 3190, trop x1 negative, creatinine of 1.3 and UA negative for infection. Imaging significant for : EKG - sinus rhythm CXR - pulmonary edema Patient was given: ___ 21:50 IV Furosemide 80 mg ___ 22:25 IV Ondansetron 4 mg ___ 22:25 IV LORazepam 1 mg ___ 22:35 PO Potassium Chloride 40 mEq On the floor, patient reports improvement in his breathing. He reports his daughter came back from ___ on ___ and has been throwing up and having loose stools. He reports as of yesterday, he has been having nausea, abdominal pain and throwing up as well. He feels over the weekend, he has noticed his ankles swell up more and has had some weight gain. He was walking around watering his plants when he experienced sudden onset dyspnea (which is moderate exertion for him). He has been exercising every other day to lose weight for a scheduled ?partial nephrectomy for newly diagnosed renal mass in the near future. He reports he has not felt anything like this before. Denies any chest pain at the time. Reports he did experience some orthopnea. He has been taking his medication as prescribed and did notice an improvement in his breathing after he received the IV Lasix in the ED. Review of systems: (+) Per HPI Radiology showed Cardiomegaly and moderate pulmonary edema consistent with congestive heart failure. The patient was diagnosed with Heart failure, unspecified. The patient was treated with N/A. At the time of discharge, the patient had PRIMARY ====== Acute on Chronic Systolic CHF Cardiogenic Shock SECONDARY ======== ___ on CKD CAD s/p CABG Renal Mass GERD BPH. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ man with complicated medical comorbidities including CAD status post three-vessel CABG, along with systolic CHF with EF around 30%, with recent finding of kidney mass suspicious of RCC presenting for sudden onset dyspnea. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman, factor V leiden carrier not on anticoagulation, who had a syncopal event with headstrike earlier on ___. She reports she felt unwell upon awakening, having noted chest heaviness, plus left ankle and calf soreness. While at the bank, she felt diaphoretic and dizzy, and subsequently lost consciousness, striking her head on the fall. She awoke in the ambulance and was alert and aware of her surroundings. She denies any prior syncopal episodes or prior clots or taking anticoagulation. UNILAT LOWER EXT VEINS LEFT showed 1. Extensive thrombus is noted within the left common femoral vein and extends into the superficial femoral, duplicated popliteal veins, posterior tibial, and peroneal veins. Of note, the proximal extent of the clot is not seen and could extend into the pelvis. 2. No evidence of deep venous thrombosis in the right lower extremity veins. CT ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST showed 1. Compression of the left common iliac vein by the right common iliac artery with complete thrombosis of the left common iliac vein extending down into the left femoral vein. 2. Incidental findings of cystic lesions within the tail of the pancreas as well as a 2.3 cm left adnexal cyst. RECOMMENDATION(S): Non urgent MRCP is recommend for further evaluation of the pancreatic tail lesions. Non urgent pelvic ultrasound is recommend for further evaluation of the left adnexal cyst. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 9:09AM, 10 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Stable globular focus of subarachnoid hemorrhage in a left medial frontal sulcus. 2. Stable small left parafalcine subdural hematoma without mass effect on the brain parenchyma. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Stable focus of subarachnoid hemorrhage in the left medial frontal sulcus. 2. Stable left parafalcine subdural hematoma. 3. No evidence of mass effect or midline shift, new hemorrhage or acute infarct. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Stable left medial frontal sulcus parafalcine subarachnoid hemorrhage. 2. Stable small left parafalcine subdural hematoma. 3. No evidence of mass effect or midline shift, new hemorrhage or acute infarct. The patient was diagnosed with Syncope and collapse. The patient was treated with 1. IVC filter placement. At the time of discharge, the patient had 1. bilateral pulmonary emboli 2. subarachnoid hemorrhage 3. left DVT. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___- A Fib with RVR (asymptomatic), given dilt 10mg x1. CT head - stable SAH. CT abd/pelvis - thrombus extends to just ___ to confluence of iliac veins. Went to OR and had IVC filter placed. Occasionally goes back into a-fib with RVR. Started on dilt gtt. BP remains stable despite RVR. Mentates well. ___- PO dilt started 45 Q6, dilt gtt weaned, then recurrent a fib RVR, back on dilt gtt, increased PO 45->60 Q6; carotid US done; EKG shows persistent prolonged QTc (489); SQH BID started per NSGY ___- added metoprolol 12.5mg po BID to wean dilt gtt. Plan for anticoagulation tomorrow agreed upon by ACS and NSGY: baseline CT head in AM -> heparin gtt (target PTT 60-80) -> repeat CT head when therapeutic; start Coumadin. ___- Started on heparin. Pre and post heparin CT head stable. Heparin at goal PTT. ___- Transfer to SICU for sustained afib w RVR. On arrival, tried metop 5 IV x2 with spontaneous break into sinus, nonsustained. Dilt 15 mg IV x1 given with rate control. Continue PO regimen, converted to metop TID, continued dilt PO 60 q6h, ___ consult for IPMN, 2 brief runs of afib w rvr to 140s spontaneously resolved ___- intermittent a fib RVR, self-limited, BP always stable; in AM, PO dilt increased to 90 QID. Cardiology consulted. Recommended amiodarone load (200 TID x 2 weeks) and diltiazem decreased to 60 QID. Metoprolol left at 25 TID. ___: O/n, HR variability worse since decreasing PO dilt and stopping IV dilt. Amio increased to 400 BID, dilt ___ q6h per cards, recs (should get dilt x2 doses ___ then d/c in ___. Home HCTZ held for low BPs in the setting of other anti-HTN meds. Given warfarin 2.5mg. Diltiazem 30 held once in ___ for hypotension. ___: 5mg warfarin FLOOR COURSE: The patient was transferred to the floor and did well. She was bridged from a heparin drip to warfarin, and her heparin drip was discontinued on ___ once her INR became therapeutic>2. She was also continued on metoprolol and amiodarone for her atrial fibrillation and remained rate controlled throughout the remainder of her stay. Of note, the pancreas surgery service was consulted for an incidentally found cystic lesion of her pancreas, likely an IPMN. She will follow up with Dr. ___ in pancreatic surgery clinic in the next few weeks. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman with Crohn's disease (complicated by fistulas & abscess in the past) s/p colectomy, as well as DVT on Warfarin for the past 2 months who presented to the ED due to 2 weeks of abdominal pain, fever today and outpt MRI today demonstrating intra-abdominal abscess. . At his baseline he is very functional, maintaining a demanding job, with plans to travel to ___ next week for business. But for the last 2 weeks he has felt stabbing pain to the right of his belly button. At first he thought it was muscle strain from weightlifting. The pain started out mild but is now severe, ___. He has felt a hard lump in the area as well. On the day of presentation, he went to an outpatient GI appointment, where he was refferred for U/S. It was felt that this might represent a spigelian hernia or hematoma in the setting of Warfarin use, but he was also referred for MRI to r/o abscess. The MRI showed 51mm x 60mm x 68mm RLQ abdominal abscess and possible fistulous tract, so he was referred to the ED. . In the ED, initial VS were: pain ___, T 101.1, HR 76, BP 146/73, RR 16, POx 100%RA. Labs were notable for WBC 15.7, ESR 44, CRP 33.1, and INR 4.0. GI consult suggested PPI, Zosyn, and continuing ___ at his current dose. It was felt that the abscess may be amenable to ___ drainage. He received Zosyn 4.5g IV. Also received Tylenol ___ PO and Dilaudid 2mg IV for pain. Was given Vitamin K 10mg IV, Protonix 40g IV, and 1L normal saline. Dr. ___ GI) was called from the ED and requested Medicine admission. On the floor, he feels fine because he just received pain medication. The pain becomes very severe between doses of pain meds. REVIEW OF SYSTEMS: (+) -easy bleeding since starting Warfarin -bloody ostomy output since starting Warfarin -abdominal hernia seems the same as usual (-) Denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, tarry output from ostomy, dysuria, hematuria. This is a ___ patient with history of Crohn's disease that involves the large and small bowel. The patient is status post multiple resections of the terminal ileum and resection of the rectum. The patient has left colostomy. The patient is now presenting with right-sided pain. The request is to rule out fistula. COMPARISON: Ultrasound examination from ___. CT of the abdomen from ___. TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 Tesla magnet including dynamic 3D imaging obtained prior to, during, and after the intravenous administration of 8 cc of Gadovist. 900 cc of barium sulfate was given orally. In addition, 1 mg of IM glucagon was administered to reduce bowel motion. FINDINGS: A fluid filled multiloculated collection is seen in the right lower quadrant. The collection measures 51 x 60 (12, 28) x 68 mm (1001, 68). The collection extends into the right abdominal wall (12, 16) and shows persistent rim enhancement. The collection is surrounded by multiple thickened ileal loops that shows mucosal hyperenhancement (12, 59 and 12, 57 and 1001, 66). No discrete fistula is seen between the bowel loops and the collection; however, in some regions there is no fat plane between the bowel loops and the collection (1001, 16). Mild-to-moderate fat stranding is seen in proximity to the collection (1002, 61). The patient is status post multiple resections of the terminal ileum and resection of the rectum. Susceptibility artifacts are seen along the proximal colon. Left-sided colostomy is seen. The rest of the small and large bowel shows no mucosal hyperenhancement or thickening of the wall that suggest inflammation. Bilobed structure is seen in segment VI of the liver. The lesion shows high signal intensity on T2-weighted images and shows no enhancement. The lesion measures 9 x 50 mm (11, 23) and is most consistent with simple liver cyst. Otherwise, the liver is normal. There is no intra- or extra-hepatic biliary duct dilatation. Cholelithiasis is seen without signs of cholecystitis. The spleen is within normal limits. Note is made of a small splenule. The pancreas shows normal signal and is within normal limits. The adrenals are unremarkable. Multiple lesions are seen within the kidneys. The lesions show high signal intensity on T2-weighted images and no enhancement post-contrast, consistent with simple cysts. No free fluid or lymphadenopathy are detected. The aorta and its branches are patent and of normal caliber. The portal vein and its branches and the splenic vein are patent and of normal caliber. Normal bone marrow signal is seen. IMPRESSION: 1. Walled off abscess is identified in the right lower quadrant. The abscess extends into the right abdominal wall. 2. Thickened ileal loops with mucosal hyperenhancement on arterial phase are seen in proximity to the abscess, consistent with active Crohn's disease. 3. Cholelithiasis without signs of cholecystitis. These findings were discussed by Dr. ___ Dr. ___ by phone at 4 p.m. ___. showed 1. Walled off abscess is identified in the right lower quadrant. The abscess extends into the right abdominal wall. 2. Thickened ileal loops with mucosal hyperenhancement on arterial phase are seen in proximity to the abscess, consistent with active Crohn's disease. 3. Cholelithiasis without signs of cholecystitis. These findings were discussed by Dr. ___ Dr. ___ by phone at 4 p.m. ___. Radiology showed Bilobed-shaped intra/ extra abdominal cystic lesion at the level of the lateral border of the right rectus abdominis muscle. This could represent a resolving hematoma/ abscess or a spigelian hernia containing fluid. Given the acuity of onset and skin discoloration reported by the patient, a hematoma is favored. However, the intra-abdominal communication is less typical of a hematoma and abscess or hernia is not excluded. Correlate with MRE performed the same day. Findings were discussed with Dr ___ by Radiology ___ over telephone on ___ at 4: 15 p.m Radiology showed Successful CT-guided percutaneous drainage catheter placement into right lower quadrant intra-abdominal abscess. Sample of the aspirate sent for microbiological analysis. Sinogram shows no communication with bowel. Radiology showed 1. The previously described abscess in the right lower quadrant has significantly resolved when compared to prior imaging and now measures 1.4 x 2.5 x 3.2 cm with a catheter noted in good position. No fistulous communication is demonstrated between this collection and the adjacent small or large bowel. There is no evidence for recurrent Crohn's disease in the small bowel. 2. Cholelithiasis. The patient was diagnosed with PERITONEAL ABSCESS. The patient was treated with ___ drainage of abscess. At the time of discharge, the patient had Primary Diagnosis Abscess Crohns Disease Microscopic hematuria Secondary Diagnosis Nephrolithiasis Urethral strictures. Rosacea. Anxiety depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PRIMARY REASON FOR ADMISSION Mr. ___ is a ___ gentleman with Crohn's disease (complicated by fistulas & abscess in the past) s/p colectomy, as well as 2 month h/o DVT (currently supratherapeutic on Warfarin) who presents with abdominal pain, fevers, and elevated inflammatory markers in the setting of intra-abdominal abscess. . #. Abdominal pain, R side: The patient was noted to have an abscess in the RLQ extending to the abdominal wall. There was no evidence of fistula or active crohn's disease on MRE. The patient was started on broad spectrum antibiotics with zosyn. A drain was placed by ___ and drained serosanguinous fluid. Culture of the fluid grew 2 species of pan sensitive E. Coli. The patients antibiotics were narrowed to oral cipro/flagyl. The patient was also continued on his home ___. Pain improved and the patient was slowly advanced to a low residue diet. At the time of discharge the patient had been afebrile x 48 hrs and WBC had normalized. Repeat CT demonstrated the abscess had greatly reduced in size and had decompressed. Drain output decreased to the point that GI and ___ were comfortable removing the drain, and the drain was removed. The patient was discharged home. He will follow-up with Dr. ___ at which time his antibiotic course will be determined. He will eventually need a repeat CT Scan to document resolution of the abscess. . #. LLE DVT: The patient was diagnosed with a DVT 2 months prior to admission. He has been anti-coagulated with warfarin. INR on admission was supratherapeutic at 4.0. He was given 10 mg of IV vitamin K prior to placement of drain. Following the procedure he was started on a heparin gtt and transitioned to lovenox. In discussion with his PCP the decision was made not to restart his warfarin, but continue on Lovenox alone. The patient will follow-up with his PCP regarding his ___. . # CKD: Cr at baseline throughout admission. He was pre-hydrated prior to CT. . TRANSITIONAL ISSUES - full code - final fluid cultures and blood cultures were pending at the time of discharge - Patient will follow-up with his gastroenterologist Dr ___ in addition to his PCP.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ history of atrial fibrillation on Eliquis and hypertension who presents as transfer from ___ with melena. CHEST (PORTABLE AP) showed 1. No pneumoperitoneum. 2. Cardiomegaly. 3. 7 mm nodule projecting over the left lower lung, which should be followed up with a chest CT on a nonemergent basis. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with colonoscopy (___). At the time of discharge, the patient had PRIMARY DIAGNOSIS: ================== post-polypectomy lower gastrointestinal bleed SECONDARY DIAGNOSES: ==================== atrial fibrillation hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY STATEMENT: ================== ___ history of atrial fibrillation on Eliquis and hypertension s/p recent polypectomy on ___ who presents as transfer from ___ with melena, now s/p colonoscopy on ___ with 3 clips to cecal EMR site and ascending colon polypectomy site. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year female with no PMH presenting to the ED s/p bike accident. Per family, she was riding her bike and hit a stick in the road and fell off her bike, + LOC, no helmet. Per the family, when they went back to see her she was unresponsive at the scene, whole body tremors and "foaming" at the mouth, this episode lasted for approximately 30 seconds, - incontinence. After episode, was confused and within ___ minutes was oriented but drowsy. + nausea, + headache. She complains of right hip and right elbow pain in the trauma bay. Radiology showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST showed Hyperdensity in the region of the left sylvian fissure, potentially artifactual although subarachnoid hemorrhage cannot be excluded. Repeat exam is suggested. No other evidence of acute intracranial hemorrhage. Right frontal scalp swelling without underlying fracture. NOTIFICATION: Findings discussed by Dr. ___ with Dr. ___ at 24:30 on ___ in person at time of discovery. CT C-SPINE W/O CONTRAST showed No cervical spine fracture or malalignment. Radiology showed 1. No acute soft tissue or organ injury within the torso. 2. Small amount of free fluid in the pelvis, nonspecific and can be physiologic but correlation with physical exam is suggested. 3. Minimally displaced fracture of the right acetabulum involving the anterior and medial walls with fracture line extending to the right iliac wing. 4. Minimally displaced fracture of the parasymphyseal right pubic bone at the pubic symphysis. 5. 4.9 cm well-circumscribed fat containing lesion at the left adnexa, compatible with a dermoid. NOTIFICATION: Findings discussed with Dr. ___ the trauma team in person, at 16:30 on ___, 2 minutes following discovery. Finding of free fluid was subsequently discussed by Dr. ___ with Dr. ___ the phone. Radiology showed Acute open displaced fracture of the right olecranon. PELVIS (AP ONLY) PORT showed Full extent of the nondisplaced fracture involving the right acetabulum, superior pubic or a mass, and extend into the right iliac wing are shown to better advantage by the torso CT and oblique views of the pelvis obtained today. CT HEAD W/O CONTRAST showed Interval evolution of left temporal subarachnoid hemorrhage along the sylvian fissure. No definitive new intracranial hemorrhage or infarction. ELBOW, AP AND LAT VIEWS IN O.R. RIGHT showed Screening for procedure guidance. SHOULDER 1 VIEW RIGHT showed No fracture or dislocation in the right upper humerus, imaged right scapula and distal clavicle and adjacent ribs. PELVIS W/JUDET VIEWS (3V) showed Right acetabular fracture extends into the right iliac wing posteriorly to the upper margin of the RPO view. Both femurs are intact. KNEE (AP, LAT AND OBLIQUE) LEFT showed Small effusion. No acute fracture is seen. KNEE (AP, LAT AND OBLIQUE) RIGHT showed Small effusion. No acute fracture is seen. Radiology showed Several fluoroscopic images from the operating room demonstrate placement of 2 screws in the right hemipelvis. Single screw is seen within the right iliac bone and a second screw is seen through the superior pubic rami along the iliopectineal line. This is fixating a minimally displaced acetabular fracture. No hardware related complications are seen. The patient was diagnosed with Disp fx of olecran pro w/o intartic extn right ulna, init, Unsp fracture of right acetabulum, init for clos fx, Traum subrac hem w LOC of 30 minutes or less, init, Pedl cyc driver inj pick-up truck, pk-up/van in traf, init. The patient was treated with ___: Open reduction, internal fixation, right olecranon using tension band.Irrigation and debridement including skin, subcutaneoustissue, muscle and bone, excisional debridement of hematoma, right elbow. ___: Open reduction, internal fixation of right anterior column acetabular fracture with intercolumnar screws and supra-acetabular screws with minimal invasive exposure. At the time of discharge, the patient had Anterior column acetabular fracture, right side Right open olecranon fracture Left subarachnoid hemorrhage. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ yo F who was admitted to the Acute Care Trauma Surgery service on ___ after a fall from her bike. Her CT images showed a small SAH, a right acetabular fracture, and right elbow/olecranon fracture with overlying open wound. Neurosurgery was consulted for the SAH and recommended a repeat head CT and Keppra for seizure prophylaxis. The repeat head CT was stable, the patient was alert and oriented and neurologically intact with no evidence of seizure activity. Orthopedic surgery was consulted for the acetabular fracture and right elbow/olecranon fractures and recommended surgical repair. Given concern for the SAH the patient was admitted to the Trauma Surgical ICU for close neurological monitoring. The patient was hemodynamically stable. She was kept NPO with maintenance IV fluids. On HD2 informed consent was obtained and the patient was taken to the operating room with orthopedic surgery for an open reduction, internal fixation of the right olecranon and an irrigation and debridement of the right elbow. She tolerated the procedure well. Please see operative report for details. She was advanced on a regular diet. She remained hemodynamically stable and neurologically intact and was transferred to the floor for further management. She was kept NPO at midnight with maintenance IV fluid. On HD3 informed consent was obtained and she was taken to the operating room with orthopedic surgery for an open reduction, internal fixation of the right anterior column acetabular fracture. She tolerated the procedure well. Please see operative report for details. Given her negative C-spine and physical exam, her cervical collar removed. Her pain was initially controlled with IV morphine and then transitioned to PO oxycodone and IV dilaudid for breakthrough once tolerating a regular diet. On HD4 she was tolerating a regular diet and fioricet was started for headache with good pain control. Her foley catheter was removed and she voided without difficulty. She was evaluated by physical therapy for mobility assessment and teaching and occupational therapy for a right arm splint. On HD5 lovenox SQ daily was started per orthopedic surgery for DVT prophylaxis. She remained hemodynamically stable and continued to work with physical therapy and occupational therapy, who recommended discharge to home with services at a wheelchair level given her weight bearing status. During this hospitalization, the patient was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient initially received subcutaneous heparin and then started on lovenox subcutaneously on HD 5 after her orthopedic surgeries. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, independently mobilizing, voiding without assistance, and pain was well controlled. The patient was discharged home with ___ and ___ services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Follow up appointments were scheduled with orthopedic surgery. She was advised to follow up with cognitive therapy as needed. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ MEDICINE ATTENDING ADMISSION NOTE . Radiology showed No acute intracranial process. Radiology showed 1. Small subcentimeter hypodensities throughout the liver, likely small cysts, though too small to characterize. 2. 1.6-cm hypodense lesion in the interpolar region of the right kidney, likely a hyperdense parapelvic cyst. Non-emergent renal ultrasound is recommended for further evaluation. 3. Severe degenerative changes of the lumbar spine with loss of height at multiple levels, though no malalignment. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, THROMBOCYTOPENIA NOS. The patient was treated with TEE (___). At the time of discharge, the patient had Strep Bovis pneumonia, meningitis and bacteremia hyponatremia hypocalcemia thromobocytopenia Sjogrens sydrome hematuria. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>. The patient is a ___ year old female with h/o HTN, osteoporosis, COPD who presents with headache, fevers and back pain s/p trigger finger injections and a reclast injection also found to have PTL = 6K on presentation with a CXR also demonstrates PNA. . # Community acquired PNA/ Mennigits: The patient is asplenic and this likely contributing to the patient having Strep Bovis infection, although the original source is unclear. Due to her delayed presentation, the patient likely became bacteremic and developed meningitis from this. Upon her presentation from ___ clinic, the patient was empirically started on vanco/CTX and dexamethasone. LP was deferred in the ED due to low platelets. The patient was followed by ID in-house, and no CSF sample was acquired as it was unclear how it would changed management. She had a PICC line placed and she will be sent home on 14 days of CTX at 2grams IV twice daily, end date is ___. Rheumatologic causes of her symptoms where also considered and the rheumatology team was consulted. They thought that her meningeal signs were less likely due to systemic lupus and more likely due to acute infectious issues. She did have some leukocytosis on discharge with a WBC# of 16K, but was afebrile and without any new or concerning localizing symptoms. . # Strep Bovis bacteremia The patient had blood cultures positive for Strep Bovis on presentation. TTE was checked which was negative for vegatations, as was a TEE. Subsequent blood cultures cleared. The patient had a picc line placed and sensitivities returned with pan-sensitive Strep Bovis, so the patients coverage was narrow down to CTX 2gm IV BID for a 2 week course ___ - ___. She will be followed in ___ at ___ and will also need to have an outpt colonoscopy to further evaluate her Strep Bovis bacteremia and r/o underlying occult malignancy in her lower GI tract. . # Thrombocytopenia This was likely due to her acute infection, but ITP was also considered in the diagnosis. Hematology was following the patient and she was placed on dexamethasone for 3 days. The patient smear showed megakaryocytes and did not show signs of MAHA. With this treatment and treatment of her infectious issues, her platelets count improved. She showed no signs of active bleeding (other then microscopic hematuria) and her Hgb was stable. The patient should have a repeat CBC 1 week after d/c and should follow with ___ Hematology Dr. ___. By day of discharge (___), her plt count had returned to normal levels, with a count of 250K, with a nadir of 6K on day of presentation to ED (___). . # Hyponatremia: This was likely due to dehydration from acute illness. The patient was also found to be taking in fairly large amounts of free water in house. As a result, the patient was free water restricted and and her HCTZ was also held. With these interventions her sodium improved and was stable at 134 on day of discharge. #Hypocalcemia: The etiology of this was unclear but vitamin d deficiency, autoimmune hypoparathyroidism and rheumatologic phenomenon where considered (see below). The patient was repleted in house mostly because she was experiencing facial twitching which was thought to be due to low calcium. The patients PTH was found to be within the normal range. Her vitamin d level was also checked and it was low at 20. She should f/u with her outpt Endocrinologist for further management. . # Sjogrens syndrome The Rheumatology team accessed the patient in house and though that systemic lupus was unlikely but that the patient should start treatment with artifical tears and artificial salvia for sjogrens syndrome. Furthermore, they also recommended treatment for oral ___, the patient was started on nystatin. The patient should follow with Rheumatology as an outpatient. . # microscopic hematuria Pt was noted to have microscopic hematuria x 2 on UA. She had no urinary symptoms, and it is possible that she had some bleeding in the setting of low plt count. However, once her plt count responds, she will need a repeat UA in the outpt setting to assess for resolution of her hematuria. If it persists, she will need further w/u for hematuria. . #Transitional Issues [] repeat CBC in 1 week and fax to PCP/Hematology, will need to assess her plt # and her WBC #, given thrombocytopenia during the hospitalization and also leukocytosis of unknown etiology on discharge. [] follow up with Hematology, Rheumatology, ID clinic and PCP [] follow up any pending blood cultures (surveillance blood cx's from ___, no growth to date) [] complete course of antibiotics with IV Ceftriaxone 2gm IV BID x 2 weeks, f/u with ID [] outpt colonoscopy to further w/u her Strep Bovis bacteremia [] electrolyte check as an outpt to check her sodium levels for stability [] repeat UA as outpt to assess for microscopic hematuria . . </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with nausea, vomiting, abdominal pain for three four days. Symptoms triggered only after eating; patient essentially asymptomatic when not eating. Abdominal pain sharp, epigastric/RUQ, and radiating to back. No fevers or chills. No diarrhea. No chest pain or dyspnea. Seen in local ED two days ago, complaining of back pain, given cyclobenzeprine. Yesterday, during hemodialysis, looked unwell, brought back to local ED with SBP 84 mmHg. Given history, concern for biliary pathology. Labs obtained, T. bili, alkaline phosphatase, and INR elevated. Ultrasound suggestive of common bile duct obstruction. The patient has penicillin allergy, was given levofloxacin (per report, no documentation), vitamin K (per report, no documentation), gentle IV fluid bolus, and transferred to ___ for ERCP. . ___ ED Course (labs, imaging, interventions, consults): - Initial Vitals: 99.4 78 90/43 18 95% 4L Nasal Cannula - guaiac negative . Upon tranfer from ED: Mental Status: alert and oriented x 3, very pleasant Lines & Drains: #22g IV in left DH-after multiple attemps, very poor access. Fluids: NS 500 cc bolus Drips: Received flagyl 500mg IV, and 2 units of FFP Precautions:Universal Belongings: with patient Most Recent Vitals: 98.3 79 92/44 23 99%RA . Upon arrival to floor, patient felt well. Denied abdominal pain, no nausea. No other complaints. . 12 point ROS as noted above, otherwise negative. Radiology showed 1. No MRCP evidence of choledocholithiasis. 2. Low and medial insertion of the cystic duct, anatomic variant. 3. Incompletely characterized focal lesion in segment ___ of the liver, slightly hyperintense on T2-weighted images, and not well evaluated without contrast. Dedicated hepatic imaging or comparison with prior studies suggested for further characterization. Given ESRD/hemodialysis, consideration could be made for multiphasic CT with IV contrast, and coordination with dialysis schedule. 4. Multiple cystic lesions in the pancreas, the largest of which measures about 11 mm in size in the pancreatic neck. A followup MRI could be considered in six months (as clinically indicated) to ensure stability, or comparison to prior studies. MRCP findings were discussed with Dr. ___ by Radiology ___ over phone on ___ at 3:15 p.m. The patient was diagnosed with CHOLELITH/CHOLEDOCHOLITH, NO CHOLECYS, NO OBS, ABNORMAL COAGULATION PROFILE, ADV EFF ANTICOAGULANTS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN. The patient was treated with ERCP ___. At the time of discharge, the patient had cholangitis choledocholithiasis esrd protein c deficincy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with history of IDDM, HTN, ESRD on HD, protein C deficiency complicated by DVT s/p IVC filter presented with nausea, vomiting, and abdominal pain with labs and imaging suggestive of choledocholithiasis/cholangitis without evidence of pancreatic involvement. IV Ciprofloxacin and Flagyl were started. She met severe sepsis criteria based on source of infection and leukocytosis, hypotension, and elevated lactate. She was kept NPO and an ERCP was performed demonstrating a moderate diffuse dilation at the main duct with the CBD measuring 14 mm. A large filling defect was suggestive of stone in the lower third of the common bile duct. Sphincterotomy was performed. Pus was seen flowing through the ampulla after the sphincterotomy. Multiple dark stones matted together, large amount of sludge and pus were extracted successfully using a 12 mm balloon. Cipro and Flagyl were continued. Blood cultures from ___ were negative. Blood cultuers from ___ and ___ were unfinalized. She remained afebrile. LFTs remained elevated with bilirubin in mid 7 range. MRCP was done noting the following per MRCP report: low and medial insertion of the cystic duct (anatomic variant), incompletely characterized focal lesion in segment ___ of the liver, slightly hyperintense on T2-weighted images, and not well evaluated without contrast was noted. Dedicated hepatic imaging or comparison with prior studies was suggested for further characterization. Multiple cystic lesions in the pancreas, the largest of which measures about 11 mm in size in the pancreatic neck. She was tentatively scheduled for cholecystectomy pending the MRCP and repeat LFTs. LFTs remained elevated. OR was cancelled and a repeat ERCP was done on ___ noting 1 cm narrowing in the distal common bile duct. This was likely due to post-sphincterotomy edema vs neoplasia. Brushings were performed from the narrowing and sent for cytology. Balloon sweep retrieved some sludge. A 5cm by ___ double pig tail biliary stent was placed successfully. Post procedure, she was stable. T.bili decreased slightly. Amylase and lipase were 58 and 156 respectively. Clear diet was advanced the next day without nausea, vomiting or abdominal pain. Blood sugars were managed with sliding scale insulin. Lantus was added once regular diet was taken on ___. Hemodialysis was performed on ___ without incident. Home meds ___, CCB and statin) were resumed on ___. She felt well enough to go home on ___ and was discharged to home. Of note, given MRCP finding of segment ___ lesion, tumor markers were sent (CA ___, CEA and AFP). Results were pending at time of discharge. IV cipro and flagyl were switched to po form. She was instructed to continue these antibiotics for 5 more days upon discharge from hospital. Coumadin had been on hold given procedures and possible OR. Coumadin was resumed on ___ using home dose of 3mg per day. Coumadin management was to be done by her outpatient nephrologist at ___ in ___. She was discharged to home in stable condition with f/u appointment with Dr. ___ on ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with history of CAD with previous MI, HTN, and ESRD on peritoneal dialysis presents with 1 day of sharp, right-sided chest pain. Patient reports that pain began last night after she ate watermelon. As she was finishing eating, she developed ___ pain in the Right side of her chest and throughout her abdomen. She notes that she felt gurgling in her stomach and was belching. She had a single episode of diarrhea. Afterward, the pain in her chest persisted. She describes the pain as radiating to her back. No associated Left-sided CP, SOB, jaw pain, diaphoresis. Pain cannot be reproduced with palpation of chest wall. Pain was not relived by BMs or belching. Pain persisted until today, and she called EMS to bring her to the ED. Of note, patient has had a cough over the past few days. Denies fever, chills. Of note, patient did go on a long car ride to and from ___ in ___, but did not notice any leg swelling in that setting. While in ___, she did not some increased ___ leg swelling/pain. No erythema. In the ED, initial vitals were: 98.0; 75; 162/84; 16; 95% RA Labs notable for: 7.8>12.3/37.2<275 K: 5.6 BUN/Cr: 41/7.1 Trop 0.04 UA w/3 WBCs and >600 prot. D-dimer 2571 Imaging notable for: B/L LENIS: IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. CXR IMPRESSION: Bibasilar atelectasis. Patient was given 4mg IV morphine Vitals prior to transfer: 98.1; 73; 147/77; 17; 99% RA On the floor, patient reports continued pain in her chest. Otherwise, she reported feeling well. CHEST (PA AND LAT) showed Bibasilar atelectasis. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had PRIMARY Musculoskeletal chest pain SECONDARY: End Stage Renal Disease Diabetes Mellitus Hypothyroidism Depression Hypertension Anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F w/ ___ CAD w/ previous MI, HTN, ESRD on peritoneal dialysis presents with sharp right sided chest pain. EKG revealing normal sinus rhythm, V/Q scan low probability, CXR clear, trops negative x2, and therefore unlikely to be ACS, PE, pneumothorax, or pneumonia. Pain was reproducible on palpation on exam and therefore suspect patient has a musculoskeletal chest pain such as costochondritis. Patient received peritoneal dialysis overnight while hospitalized and her electrolytes were wnl on discharge. #Musculoskeletal Chest Pain Pain was reproducible on palpation on exam and therefore suspect patient has a musculoskeletal chest pain such as costochondritis. EKG revealing normal sinus rhythm, V/Q scan low probability, CXR clear, trops negative x2, and therefore unlikely to be ACS, PE, pneumothorax, or pneumonia. Patient's pain was improved with tylenol and she was stable for discharge #End stage renal disease Patient with hyperkalemia in the setting of ESRD. No EKG changes. Patient received peritoneal dialysis while hospitalized. Patient was continued on nephrocaps #Hypertension Patient's BP goal <170 per renal team, which was at goal during hospitalization. Patient was continued on home lisinopril, isosorbide mononitrate #CAD Stable. Patient was continued on home atorvastatin, metoprolol, lisinopril, and aspirin #Diabetes Mellitus Stable. Patient continued on home glargine and insulin sliding scale #GERD. Patient was continued on home PPI #Hypothyroidism/Neuropathy/Gout Stable. Continued home amitriptyline, levothyroxine, and allopurinol</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with a history of hypothyroidism, hypertension, atrial fibrillation on Coumadin presenting with 24 hours of abdominal discomfort, diarrhea. Patient reports yesterday morning she began having diarrhea, no bowel movement for 6 hours and then had almost one episode of diarrhea every hour even throughout the night until today. She notes that she may have had around 20 BM in that entire period. Patient reports the diarrhea is watery with no tenesmus, blood or mucus. Patient feels bloated with multiple lot of gas in her abdomen and nauseous as well last night. She attributes these symptoms to a salad that she ate at ___ one day prior to initiation of symptoms. She has had no recent sick contacts. There is no fever, chills, vomiting, flank pain, dysuria or vaginal discharge or bleeding. Radiology showed 1. RECOMMENDATION(S): Dedicated renal ultrasound on a nonemergent basis. The patient was diagnosed with Other specified noninfective gastroenteritis and colitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH of afib on Coumadin who presented with 24 hours of diarrhea likely ___ viral gastroenteritis who improved after receiving 2L of NS in the ED and was able to tolerate po well without significant diarrhea.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with PMH of laryngeal cancer s/p tracheostomy, DM II, minimal change disease on chronic prednisone and discharge from ___ yesterday for coag-negative staph UTI and bacteremia presenting from home with fevers up to 102 and diffuse weakness. He presented on ___ with 1 week of urinary retention and weakness, was admitted to ___ for septic shock, required vasopressors and stress dose steroids, was on ceftriaxone, cefepime and then vancomycin and nafcillin. ID was consulted and he was discharged on 6 week course of Vancomycin via ___ line for presumed endocarditis, TTE was negative and he was high risk for TEE given his tracheostomy. He reports feeling well when he left, developed loose stools starting last night, had 3 episodes of loose stools that he reports are soft but not watery. His ___ saw him today and he had a fever of 102, felt weak and unable to ambulate normally. ___ was concerned for bleeding and possible erythema at ___ site. Sent to ___ ED, temp 100.6, CXR was initially read as concerning for RLL consolidation, he was given cefepime and continued on vancomycin and admitted. CHEST RADIOGRAPH showed No acute cardiopulmonary process. NOTIFICATION: Final report discussed with Dr. ___ by NSR via phone on ___ at 3:35 ___. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN. At the time of discharge, the patient had Fever Secondary Staph epidermis bacteremia Diabetes Mellitus Minimal change disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male with PMH of laryngeal cancer s/p tracheostomy, DM II, minimal change disease on chronic prednisone and discharge from ___ ___ for coag-negative staph UTI and bacteremia presenting from home with fevers up to 102 and diffuse weakness. #ID: Coag-negative staph UTI and bacteremia with presumed endocarditis on 6 week course of vancomycin via ___ line. Febrile to 102 but without focal symptoms. Had some loose stools but not diarrhea. No cough or other URI symproms with an unremarkable chest xray. No voiding symptoms. Urine No signs of pneumonia or other localizing signs of infection. Urine Cx negative and Blood cx with no growth by discharge. His vanc trough was 10.1 prior to discharge and so appropraite dose increases were made. He was afebrile throughout his hospital stay with no new symptoms. His Vancomycin trough was 14.1 prior to discharge and vancomycin increased to 1500mg q12 hours. Next trough to be checked by ___ and faxed to Dr. ___. He will complete a ___s previously planned, with ID follow up. #GU: Hx of BPH. Negative urine culture Continued flomax and finasteride #Renal: Minimal change disease on chronic prednisone, creatinine at baseline. Continued prednisone 10 mg daily #CV: HTN, HL: continued amlodipine, lisinopril and aspirin #DM II: Continued lantus and lispro sliding scale</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH severe depression NPH s/p shunt placement in ___, myasthenia ___, hypothyroidism, HTN, esophageal cancer in remission, who presents to the emergency department with suicidal ideation and altered mental status. Radiology showed No evidence of pneumonia Radiology showed Right-sided VP shunt without radiographic evidence of discontinuity or kink. CT HEAD W/O CONTRAST showed 1. Left frontal convexity mixed density subdural hematoma measuring 4 mm. No midline shift. No other intracranial hemorrhage. 2. Right posterior approach ventriculostomy catheter terminates near midline in frontal horn of left lateral ventricle. No definite findings to suggest hydrocephalus although no priors for direct comparison. 3. Hypodensity involving the left caudate head may represent chronic small vessel ischemic change. MRI would be more sensitive to assess for acute infarct. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 8:05 pm, 2 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Stable small left convexity subdural hematoma, measuring 4 mm. No new hemorrhage. 2. Stable VP shunt catheter position. Stable ventricular size. SHOULDER 1 VIEW LEFT showed Fracture of the mid clavicle of indeterminate age. NOTIFICATION: The findings were discussed with ___. by ___ ___, M.D. on the telephone on ___ at 6:15 pm, within 10 minutes after discovery of the findings. CLAVICLE LEFT showed Fracture of the mid left clavicle again noted, with full shaft width displacement and overriding. Edges appear corticated, suggesting a nonacute injury. No convincing bony bridging identified.. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Unchanged small left subdural hematoma, measuring 4 mm. No new or increasing hemorrhage. 2. Unchanged ventricular catheter position. Stable ventricular size. Chest radiograph showed No acute cardiopulmonary abnormality. Left clavicle fracture is better assessed on the prior dedicated study. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had PRIMARY ======= Toxic metabolic encephalopathy Delirium SECONDARY ========= Depression with suicidal ideations Normal pressure hydrocephalus status-post VP shunt Subdural hematoma Hypothyroidism Hypertension Benign prostatic hypertrophy Left clavicular fracture Myasthenia ___ GERD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY: Mr. ___ is a ___ with past medical history of severe depression (receiving ECT), normal pressure hydrocephalus s/p shunt placement in ___, myasthenia ___, hypothyroidism, and hypertension who presents to the emergency department with suicidal ideation and altered mental status. ====================== ACUTE MEDICAL PROBLEMS ====================== # Toxic Metabolic Encephalopathy Patient presented with agitation and confusion. Was recently hospitalized elsewhere and had negative workup done, although MS improved temporarily after shunt adjustment. Workup for reversible causes ruled out infections, worsening of subdural hematoma, untreated hypothyroidism, neurosyphilis, B12 deficiency, and seizures as cause. Neurosurgery consulted and felt no issues with shunt or change in ventriculomegaly. Likely medication-induced in setting of possible underlying cognitive decline or dementia. Initially required antipsychotics for agitation, but improved with frequent re-orientation and downtitration of psychitatric medications with guidance of Psychiatry. [] Continue clonazepam 0.125 mg qAM with plan to stop on ___ [] Started clonidine 0.1mg qhs to help with restlessness [] Started Ramelteon 8 mg qhs to help maintain sleep-wake cycle [] Continue home thiamine 100 mg PO daily [] If patient becomes altered, get repeat head imaging to evaluate for worsening subdural hematoma or normal pressure hydrocephalus [] Refer back to Geriatrics at ___ for further workup of possible cognitive decline [] Continue ___ #Depression with suicidal ideation Evaluated by psychiatry in ED who issued ___ to ongoing safety assessment for suicidal ideation. Per family members, this change in his mental status was not consistent with his typical depression episodes. Psychiatry was consulted who recommended medication changes as below. Decision was made to hold off on ECT due to ongoing delirum. Patient had intermittent SI during hospitalization but without plan or intent. [] Continued mirtazipine 45 mg PO qhs [] Continued lamotrigine 50 mg PO BID [] Decreased duloxetine to 40 mg PO daily [] Stopped methylphenidate [] Stopped trazadone [] If mental status improves, consider restarting ECT [] Ensure psychiatry ___ [] Ensure patient does not have access to items available to harm himself #Goals of Care Long discussion with case management and Niece who is HCP. Plan is still DNR/DNI and plan to still readmit to hospital if rehab cannot handle symptomatic management of any acute conditions. A decision on weather to escalate care or transition to comfort measures will be made with each hospitalization. ==================== CHRONIC/STABLE ISSUES ==================== #Normal pressure hydrocephalus s/p VP shunt placement Adjusted at recent hospitalization with some improved mental status (reprogrammed from 15 to 13). This admission, shunt series performed with no concern for kink or obstruction (ventricles stable size). Neurosurgery held off on adjustment. [] If urinary retention worsens or mental status worsens, would re-image shunt #Myasthenia ___ Patient with diagnosed severe ___ after recurrent pneumonias in ___. Has been on pyridostigmine, azathioprine, and a prednisone taper. Initial concern for prednisone contributing to AMS however given severe MG, neurology believed the prednisone taper should be continued to avoid precipitating MG crisis. Paraneoplastic workup negative at ___. [] Continued Azathioprine 150 mg PO daily, prednisone 30 mg PO daily, and pyridostigmine 60 mg PO q8h [] Continue Bactrim DS tab ___ and calcium/vitamin D while on steroids # Subdural hematoma: Likely ___ to recent multiple falls. Non-contrast head CT shows left sided SDH with no mass effect. Evaluated by neurosurgery who believed SDH is likely not the cause of altered mental status. However, can definitely be contributing to the patient's overall decompensation. Completed Keppra 1000mg BID x 7 days as per neurosurgery for ppx. [] Consider head imaging if mental status worsens # Left clavicular fracture Exam notable for bulging clavicle. Per HCP, was chronic. Shoulder xray with likely chronic fracture. [] Per Orthopedics, nonsurgical management with sling [] Tylenol prn #Acute kidney injury Patient with Cr 1.4 with reported baseline around 1.1.-1.2. Likely prerenal in setting of poor PO intake. Resolved with IV fluids. #Hypernatremia Patient with mild hypernatremia in setting of poor PO intake which resolved on its own. # Hypothyroidism TSH slightly elevated at 5.1 [] Increased levothyroxine to 125 mcg PO daily [] Continue liothyronine 5 mg PO daily [] Repeat TSH as outpatient # Hypertension SBPs were controlled without medications [] Goal SBP <160 for subdural hematoma. # Benign prostatic hypertrophy Had some urinary incontinence. No urinary tract infection present. #?GERD Continued home omeprazole 20 mg PO daily. [] Discuss need for PPI #Poor PO intake Per family, had poor PO intake at home. Albumin 3.5 [] Diet: ground solid and thin liquid diet, with aspiration precautions [] MVI with nutrients TRANSITIONAL ISSUES =================== Follow up ---------- [] Refer back to Geriatrics at ___ [] PCP ___ for medication changes. Discuss need for PPI [] Outpatient psychiatry ___ --> consider ECT if mental status improving [] Follow up with Orthopedics with x-rays within 2 weeks of discharge [] Follow up neurosurgery for VP shunt monitoring and subdural hematoma [] ___ with Neurology for myasthenia ___ [] Repeat ___ Management ----------- [] Ensure SBP <160 due to subdural hematoma [] If patient with any neurologic deficits, repeat head CT immediately and called Neurosurgery [] Diet: GROUND SOLIDS and THIN LIQUIDS [] Medications: WHOLE WITH WATER [] Aspiration Precautions -1:1 supervision for meals -alert and attentive for meals -encourage PO intake -Frequent oral care (TID) [] Continue to work with ___ and OT [] Continue Bactrim DS 3x/week, calcium, and vitamin D while on steroids for ___ [] Sling for management of clavicular fracture [] Ensure patient does not have access to items available to harm himself [] Stop clonazepam on ___ ADVANCED CARE PLANNING ======================= #CODE: DNR/DNI, MOLST form filled out #CONTACT: ___ (niece), phone: ___- HCP</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o cervical cancer s/p treatment, HTN, HLD, bipolar, recent diagnosis of unprovoked LLE DVT treated with hep gtt, and discharged ___ on xarelto, presents as a transfer from ___ ___ for concern for phlegmasia cerulea dolens. CHEST (PORTABLE AP) showed No CHF, focal infiltrate or gross effusion. Probable background COPD. Heart size borderline enlarged. The patient was diagnosed with Acute embolism and thrombosis of deep vein of l low extrem. At the time of discharge, the patient had PRIMARY DIAGNOSIS: ================== Left lower extremity DVT Secondary DIAGNOSES: ==================== Hypertension GERD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with past history of hypertension, dyslipidemia, bipolar disorder, and a recent diagnosis of unprovoked left lower extremity DVT started on xarelto on ___, who presented for two days of worsening left lower extremity soreness, swelling, and purpulish discoloration with initial concern for phlegmasia. # Left Lower Extremity DVT: Initially seen at ___ but was transferred to ___ for concern for phlegmasia cerulea dolens for a vascular surgery evaluation. PAtient had worsening leg erythema, swelling, and pain despite anticoagulation. After arrival to ___, the patient was seen and evaluated by the vascular surgery to given the concern for worsening thrombosis. They deferred any additional intervention as the patient did not have evidence of total vascular flow compromise. Patient was initially switched to a heparin drip, but was subsequently restarted on Xarelto 1 day prior to discharge. Her pain and swelling improved with compression and elevation. Plan is for continued compression (thigh high stockings) and elevation ___ at home with follow-up with vascular surgery. We strongly urged the patient to continue the rivaroxaban for at least ___ year and perhaps lifelong given the extent of thrombus. We also recommended that she follow up with an outpatient hematologist/oncologist and an apt was made for ___ 10:00a with Dr. ___. The vascular surgery team plans to contact her for follow up as well. # Psychiatric history - Severe Depression and Bipolar prior history of ECT therapy. - Continued home Lexapro 20 mg po qd - Continued home Xanax 0.5 mg po qhs - Continued home clozapine 37.5 mg po qd - Continued home Latuda 80mg qd - Continued home Lithium ER 450 QHS # HTN - Continued HCTZ # HLD: - Continued simvastatin # GERD: - Continued PPI # Vitamin deficiency/macrocytosis: - Held home Cerefolin & B12 as non-formulary. - Continued Calcium, vitamin D.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a recent dx of insulin dependent DM in ___ and severe esophagitis, who presents from his ___ clinic for vomiting and blood sugar control. Radiology showed No evidence of acute cardiopulmonary disease. Radiology showed Moderate fecal loading. No evidence of obstruction. The patient was diagnosed with VOMITING. At the time of discharge, the patient had Primary: Hyperglycemia Hyponatremia Abdominal Pain Secondary: Diabetes mellitus Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a recent dx of insulin dependent DM and severe esophagitis, who presents from his ___ clinic for vomiting and blood sugar control. # Abdominal/Substernal pain: ___ have been a viral gastritis or an exacerbation of diabetic gastroparesis. No obstruction on KUB. Patient was unable to take his home gastritis/esophagitis meds given pain with swallowing and N/V. Nausea improved with IVF and IV ondansetron. Tolerated po intake without emesis prior to discharge. Continued symptomatic management with omeprazole, ranitidine, metoclopramide, sucralfate. # Diabetes/hyperglycemia: His glucose returned to normal with 3L NS. He had no anion gap, but his UA did show trace ketones. Pt reports having stopped his insulin given vomiting/abd pain. glucose now well controlled, back on home regimen. A1c 7.2. # Hyponatremia: Resolved. A component of pseudohyponatremia given hyperglycemia, however dehydration was likely playing a role in hypovolemic hyponatremia. Also BUN/Cr ratio >20 supporting this diagnosis. # Hypertension: His antihypertensive regimen was changed from chlorthalidone to lisinopril, given his history of diabetes and hypokalemia. He will be discharged on lisinopril 5mg daily, which should be uptitrated as outpatient. # Chronic pain: continued lyrica and amytriptiline # Constipation: started docusate and senna.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old male with recently diagnosed CLL and warm autoimmune hemolytic anemia presenting from ___ with chest pain, fevers, and anemia. CHEST (PORTABLE AP) showed Satisfactory position of right internal jugular central venous line, with the tip at the superior cavoatrial junction. No pneumothorax. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. Radiology showed 1. Low lung volumes with trace bilateral pleural effusions. 2. Two right upper lobe nodules, the largest which measures 4 x 7mm. This was not seen previously and could be inflammatory or a true nodule and followup chest CT in 3 months is recommended. 3. Prominent bi-axillary nodes as well as right paratracheal node, minimally changed in size when compared to prior examination dated ___ likely secondary to known CLL. 4. No pulmonary embolism. NOTIFICATION: Findings and recommendations were discussed with ___, house staff caring for the patient, by Dr. ___ telephone at 11:21, on ___. Abdominal radiograph showed 1. No abnormally dilated loops of colon to suggest megacolon. 2. No pneumoperitoneum. 3. Minimally dilated small bowel loops, measuring up to 3.0cm in diameter. NOTIFICATION: Final results were telephoned to Dr. ___ By Dr. ___ on ___ at 3:29PM. CHEST (PA AND LAT) showed Minimal increase in size of small left effusion and adjacent atelectasis The patient was diagnosed with HYPOTENSION NOS, CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION, ACQ HEMOLYTIC ANEMIA NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS ================= WARM AUTOIMMUNE HEMOLYTIC ANEMIA CHRONIC LYMPHOCYTIC LEUKEMIA DIARRHEA SECONDARY DIAGNOSIS =================== HYPERTENSION. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old gentleman with CLL and autoimmune hemolytic anemia who presents with fever, hypotension, anemia, and chest pain. # AUTOIMMUNE HEMOLYTIC ANEMIA: Patient has known direct Coombs positive warm antibody autoimmune, often triggered by acute illness. This presentation was likely in the setting of an acute diarrheal illness. On admission, his Hct was 15 and labs were consistent with hemolytic anemia. Patient was started on high dose steroids and high dose folic acid. He was transfused a total of 9 units pRBC in the ICU over the course of four days. Hct improved to 20 on transfer to the floor. On the floor he was continued on 40 mg IV methylprednisolone. He required an additional four units of packed red blood cells on the ___ service. While remaining on the 40 milligrams IV methylprednisolone Q12H, he did undergo rituximab infusion on ___ and ___. At the time of discharge his H/H was 7.3/23.1. He did not require any blood transfusions in the six days prior to discharge. He was transitioned to prednisone 80 milligrams PO daily and was discharged on this medication regimen. He was continued on folic acid 5 mg PO daily. He was also discharged on acyclovir and bactrim given the chronic steroid use. Of note: PND labs were negative. G6PD was 25.8. # LEUKOCYTOSIS/FEVER: WBC on admission was 32 with a neutrophil predominance, though it uptrended to 104.5. Although patient has known CLL, neutrophil predominance suggested a possible infectious process vs. steroid-induced leukocytosis. Patient was started on vancomycin, cefepime, and azithromycin initially given CLL/functional neutropenia. Infectious work-up, including C diff and stool studies, respiratory panel, and urine culture was negative. CXR was notable for atelectasis without evidence of pneumonia. Blood cultures remained negative. Antibiotics were discontinued and his WBC continued to trend down. At the time of discharge his WBC count was 10.8. # CHRONIC LYMPHOCYTIC LEUKEMIA: Confirmed by flow cytometry and FISH ___, no bothersome LAD or B symptoms so currently no plan for treatment in the near future. CT of Chest ___: showed severe adenopathy in the axillae, milder in the mediastinum. CT of Abdomen and Pelvis: Mild splenomegaly of 15.7 x 9.2 cm; moderate retroperitoneal lymphadenopathy. Patient underwent rituximab infusion as noted above. # TACHYCARDIA: Patient became persistently tachycardic with HRs to 140s on hospital day 2. Telemetry and EKG were notable for sinus tachycardia, most likely secondary to anemia given acute hematocrit coinciding with the tachycardia. CTA on admission was negative for pulmonary embolism. When arriving on the floor his tachycardia did improve. Heart rate remained around 100 bpm. Patient remained asymptomatic with this tachycardia and was hemodynamically stable while on the bone marrow transplant floor. # HYPOTENSION: Patient was hypotensive on admission and briefly required pressors. Initial concern was for septic shock given ___ SIRS criteria, though no infectious source could be identified. Blood pressure improved after blood transfusions, suggesting hypovolemic shock. After transfer to the ___ floor, his blood pressures were stable. His lisinopril and hydrochlorothiazide were stopped as his blood pressure was well controlled without these medications. # DIARRHEA: Stool culture from the outside hospital grew pseudomonas, though GI did not believe that this was the cause of his diarrhea. Repeat stool studies here, including C diff, were negative. CMV negative. Given decreased oxygen-carrying capacity in the setting of hemolytic anemia, ischemic colitis is possible, though additional work-up was deferred. Patient remained on antibiotics as noted above-vancomycin, cefepime, azithromycin. Diarrhea decreased throughout hospitalization and resolved at the time of discharge. # CHEST PAIN: Patient had chest pain on admission that responded to morphine and did not recur. EKG was unchanged and cardiac enzymes were negative. CTA was negative for pulmonary embolism. Chest pain was likely in the setting of anemia. TRANSITIONAL ISSUES =================== #PULMONARY NODULES: A CTA of the chest revealed "two right upper lobe nodules the largest measuring 4mm x 7mm." Recommendation is for follow-up CT of the chest in 3 months. #FOLLOW-UP H/H: Patient has a follow-up H/H scheduled for ___. #RITUXIMAB THERAPY: Patient underwent rituximab therapy on ___ and ___. Based on this schedule he is set to undergo his third infusion of rituximab on ___. #PREDNISONE TAPER: Discharged on prednisone 80 milligrams PO daily. He was given a prescription for 7 days. Please address tapering of prednisone as an outpatient. #CONTACT: ___ ___ #CODE STATUS: FULL CODE. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with history of alcoholic cirrhosis, alcohol abuse complicated by withdrawal seizures, asthma with multiple intubations in the past presenting with abdominal pain and SOB. Chest radiograph. showed No acute cardiopulmonary abnormality. CT abdomen pelvis. showed 1. No acute intra-abdominal abnormality. 2. Cirrhotic liver morphology with re-demonstrated mild splenomegaly and varices. No focal hepatic lesions seen. The patient was diagnosed with Unspecified asthma with (acute) exacerbation, Unspecified abdominal pain. At the time of discharge, the patient had Abdominal pain Alcohol withdrawal Asthma exacerbation Opiate dependence. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT/PLAN: ___ male with PMHx alcoholic cirrhosis, alcohol abuse complicated by withdrawal seizures, asthma with multiple intubations in the past, and chronic pain on methadone presenting with abdominal pain and SOB. # Abdominal pain-- Pt reports mid-epigastric pain on presentation radiating to back and flanks. CT a/p performed in ED negative for any acute processes or signs of acute pancreatitis. Very mild elevation in lipase. This was felt to be more likely alcoholic gastritis rather than acute on chronic pancreatitis. It was managed conservatively with bowel rest and initially IV dilaudid which was transitioned to PO after pt tolerating diet. PO dilaudid was also subsequently tapered and pt was discharged with a 2 day supply for any ongoing breakthrough pain. # EtOH w/d-- ___ was monitored on CIWA and initially required several doses of 4mg PO ativan which was tapered to 2 mg, 1 mg and subsequently off as pt was no longer showing signs of withdrawal. # SOB/Asthma exacerbation-- Pt presents with SOB and is very wheezy on exam with poor air movement. Unclear trigger for asthma exacerbation but suspect possible ?aspiration event in s/o recent ETOH intake. ___ reports medication compliance but this may have also been a precipitating factor. He was started on a prednisone burst, azithromycin, and given duonebs with improvement. # Opiate dependence-- Per reports, pt with long history of hydromorphone use/abuse with issues in the past with getting discharged from methadone clinics. Currently, he is at Habit OPCO and was continued on 80mg methadone. Pt expressed significant discontent with his pain medication regimen while inpatient. However, it was felt to be unsafe to escalate regimen more than 0.5mg IV dilaudid q4H initially as he was also getting his outpatient methadone in addition to Ativan. Staff also found him to be frequently somnolent despite reports that his pain was poorly controlled. # Elevated Transaminases-- Mildly elevated AST, Alk phos in 900's. Alk phos has been significantly elevated in 800's in the past. MRCP was done last admission in ___ and this did not show an intra- or exta-hepatic biliary duct dilatation or masses. Alk phos remained elevated throughout his stay but his AST/ALT downtrended. # Cirrhosis-- home lasix and spironolactone were held initially as pt had poor PO intake. He remained euvolemic despite holding these medications and they will be resumed upon discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of emergency repair acute Type A dissection ___ at ___ (30mm Gelveave graft from STJ - innominate artery) who presents with chest pain and concern for new dissection or aortic clot on CT scan. Patient was in his USOH until ___ when he developed a senstation that his throat was 'bruised' during inspiration. He then developed intermittent left sided chest, axilla, and back pain on ___ at rest. The pain would come and go, and could get up to ___. He notes the chest pain more when laying on his right side and the throat sensation more when he is lying on his back. Due to his symptoms, his PCP told him to proceed to ___, and he went to ___ on ___. There, a CTA showed concern for a Type A aortic dissection of indeterminate age, but no active extravasation. There was also some concern for an aortic clot at some point, although not mentioned in the read. He was then transferred to ___ for further evaluation. In the ___ intial vitals were pain 4, T 98.5, HR 106, BP 123/84, RR 18, O2 92% RA. Initial labs were notabele for WBC 11.1, INR 1.2, and trops negative x1. Remainder of CBC and chem10 were wnl. Cardiac surgery was consulted who felt that this was not an acute issue, but recommended repeat imaging in 48-72 hours. They also recommended against any anticoagulation. Patient was then transferred to cardiology for further management. Vitals on transfer were pain 0, T 97.7, HR 98, BP 130/77, RR 15, O2 94%RA. On the floor patient notes only mild throat discomfort, and denies dysphagia or difficulty breathing. He also notes he will have some chest pain as above when he rolls on his left side. Both of these are significantly improved from earlier in the week. He denies recent fevers or chills. No SOB or cough. No palpitations. No nausea, vomiting or diarrhea. No recent travel and no pain or swelling in his legs. He does note he started taking tiotropium inhaler and atorvastatin on ___ preceeding these symptoms. ROS is otherwise unremarkable. Radiology showed 1. Apparent discontinuity of the ascending aorta with communication to an adjacent hematoma/fluid collection. Hyperdense areas adjacent to this site raise concern for extravasation of contrast into a contained rupture/pseudoaneurysm. Recommend repeat multiphase chest CTA to assess for active extravasation of contrast into the adjacent mediastinal collections. Comparison with any prior post-operative chest CTs would also be helpful to determine chronicity of findings. 2. 2-cm partially thrombosed aneurysm of the left gastric artery 3. Nonspecific mediastinal and hilar adenopathy which is stable since ___ suggesting a benign etiology. 4. Borderline pelvic lymph nodes of uncertain etiology and chronicity. 5. Stable 3-cm left adrenal adenoma. 6. Ectasia of the right common iliac artery measuring 1.7 cm. 7. Diverticulosis Dr. ___ communicated the above findings and recommendations (#1) to Dr. ___ at 4:45 pm on ___ by telephone ___ minutes after discovery. DLP: 1253.56 mGy-cm Radiology showed 1. No abnormal fluid collection or lymphadenopathy in the neck. 2. Mediastinal fluid collection and aortic dissection remain unchanged since prior study on ___. Radiology showed Probable thrombosed traumatic pseudoaneurysm medial to the ascending aortic graft. The chronicity of these findings is uncertain, though given probable surrounding granulation tissue, findings are at least subacute or chronic. No acute active extravasation is identified. Comparison with prior post-operative CT examinations would be helpful. Recommend short interval followup CT (~3 months) to assess for stability and to guide any potential further interventional management. Dr. ___ communicated the above results and recommendations to Dr. ___ at 4:30 pm on ___ by telephone. The patient was diagnosed with THORACIC AORTIC EMBOLISM. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Throat pain Hypoxia SECONDARY DIAGNOSIS: Hypertension Hyperlipidemia COPD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of emergency repair acute Type A dissection ___ at ___ (30mm Gelveave graft from STJ - innominate artery) who presents with throat pain. # Throat pain: Due to the patient's history of type A dissection, there was concern for aortic dissection. CTA from the outside hospital showed evidence of dissection, but this was thought to represent a chronic flap from his previous dissection. Cardiac surgery was consulted, who recommended repeat CTA in 48 hours to evaluate for progression. Repeat CTA on ___ showed extravasation of contrast into a contained rupture/pseudoaneurysm. Radiology recommended repeat multiphase CTA to assess for active extravasation. Repeat CTA on ___ was negative for acute/active extravasation, however the patient likely had a leak in the past, given the presence of granulation tissue. Radiology recommended repeat CTA in 3 months to evaluate for progression. We were unable to obtain films from ___, where the patient was diagnosed with his dissection. However a post-operative CTA report did not note any leak. The patient remained hemodynamically stable. Blood pressure and pulses were equal in both arms. His losartan dose was increased to 50mg. The patient's throat pain resolved during hospitalization, and the etiology was thought to be due to a viral infection. # COPD: The patient denied any shortness of breath. CT chest with extensive centrilobular and paraseptal emphysema. He was also found to be slightly hypoxic (SpO2 89-91% with ambulation). The patient was continued on spiriva. Smoking cessation was encouraged. # HTN: Currently normotensive. His dose of losartan was increased to 50mg daily as losartan as it has been shown to be beneficial in patients with cystic medial necrosis. # Leukocytosis: Noted on admission labs. Differential was within normal limits. Baseline unknown. The patient was afebrile and without infectious symptoms besides throat pain. WBC trended down during hospitalization. # HLD: Continued atorvastatin.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old lady with H/O IDDM, hypertension, CAD s/p MI in ___, seizures, SLE, CKD, and recent discharge for syncope on ___ thought secondary to a seizure presents with chest discomfort, dyspnea on exertion and fatigue today of sudden onset while exerting herself. She denied palpitations but did state that her heart felt like it had slowed down dramatically when this occurred. She states she has never had symptoms like this before, but has had substernal chest pain previously upon awakening in the morning that was relieved with eating a meal. Due to these new symptoms, she went to the ED where she was felt to have sinus bradycardia to the ___ and hypertension. She was recently started on propranolol 10 mg BID by her PCP for essential tremor on ___. Her chest pain resolved by the time she reached the ED, and over the ED course, it was noted that she went from presumed sinus bradycardia to regular rhythm with rates in the ___ but with a prolonged PR interval of ~300 msec. Cardiology was consulted in the ED who felt that her bradycardia was secondary to her newly started propranolol, and recommended admission to ___ for observation. After arrival to the cardiology floor, she has no complaints. Radiology showed Chronic interstitial lung disease, but no definite evidence of pneumonia. The patient was diagnosed with CHEST PAIN NOS. At the time of discharge, the patient had Ectopioc atrial bradycardia, due to Beta blocker toxicity Chest pain Coronary artery disease Hypertension Shortness of breath Acute on chronic left ventricular diastolic heart failure Acute kidney injury Gastroesophageal reflux disease Tremor Diabetes mellitus Hypothyroidism Systemic lupus erythematosis Rheumatoid arthritis Seizure disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old lady with history of IDDM, hypertension, CAD s/p MI in ___, seizures, SLE, CKD, and syncope who presented with substernal chest pain, dyspnea on exertion and subjective feeling of her heart slowing, found to have non-sinus bradycardia and shortness of breath. Her bradycardia was felt secondary to recently starting propanolol. She was monitored in the hospital for propanolol washout, and her bradycardia resolved (as such, she did not require a pacemaker). She should avoid beta blockers in the future (now listed as an allergy). >> Active Issues: # Bradycardia: Following initiation of a nodal blocking agent, Ms. ___ presented with a symptomatic ectopic atrial bradycardic rhythm. Her propanolol was stopped, and her bradycardia resolved. She also had first-degree AV block. Hypothyroidism was less likely as a cause (TSH was wnl). Acute MI was also unlikely as she had negative troponins and no obvious ischemic ECG changes from baseline. Her chest discomfort was likely due to new bradyarrhythmia. - She was discharged in sinus rhythm and heart rate consistently between 60-70. - She should avoid all nodal blocking agents in the future. # Shortness of breath: On admission, she was mildly volume overloaded with JVD, rales, mild room air hypoxia, likely an exacerbation of her chronic diastolic CHF. She responded well to gentle diuresis with furosemide 20 mg IV. # Acute Kidney Injury: Cr of 1.7 on admission, improved to 1.2 on discharge. FENa was less than 1%, so more likely pre-renal. She endorsed poor PO intake prior to admission. ___ could also be secondary to poor renal perfusion due to decreased cardiac output when bradycardic, as well as diastolic heart failure. # Hypertension: She was hypertensive on admission, which may have caused exacerbation of diastolic heart failure. She was started on doxazosin every evening to maintain control of BP throughout the day. She was continued on her amlodipine and ACE-I. # CAD: Stable on this admission. Her chest pain today was in the setting of bradycardia, and dyspnea suggestive of exacerbation of diastolic CHF. Her more chronic symptom of morning sub-sternal pain which is relieved with food and worsened by lying down seems more related to dyspepsia or GERD than ischemic in origin. She had no evidence of MI with serial normal troponins, and was continued on her aspirin dihydropyridine calcium channel blocker, and statin. # Epigastric pain: Given the association with lying down and eating, likely dyspepsia or GERD. She was started on omeprazole for this. >> Chronic issues # History of seizures: Continued levetiracetam. # SLE: Continued prednisone, hydroxychloroquine. # DM, type 2: In house, she was managed with Humalog ISS and NPH ___. >> TRANSITIONAL ISSUES - CODE: Full. - Contact: daughter is also HCP, ___ ___ - The patient reports that she actually takes hydroxychloroquine twice daily, as opposed to alternating with lower dose. - She should avoid nodal blocking agents in the future.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year-old right-handed man without significant past medical history who presents with right ear ringing and profound dizziness with nausea and vomiting. Patient was in his usual state of health yesterday evening doing his regular gym routine which included weight lifting and elliptical work he felt at his baseline state of health after his workout and went to sleep. He woke up this morning with severe right sided tinnitus profound nausea and vomiting and extreme dizziness without visual changes. He called ___ he was taken to an OSH, where he had CTA which revealed left-sided vertebral artery dissection with basilar thrombus. He was started on a heparin GTT with bolus and transferred to ___ for further care. MR HEAD W/O CONTRAST ___ MR HEAD showed 1. Acute infarcts involving the right greater than left cerebellar hemispheres, most likely resulting from the known basilar artery thrombosis. 2. Loss of flow void is noted in the basilar artery in the same region as demonstrated on CTA from the day prior. However, complete evaluation is not possible as this is a non angiographic examination. NOTIFICATION: The finding of cerebellar infarction was documented in the clinical notes in OMR at the time of interpretation. The patient was diagnosed with Dizziness and giddiness. The patient was treated with N/A. At the time of discharge, the patient had Acute ischemic stroke Vertebral artery dissection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY: ======== Mr. ___ is a ___ year old man with no significant past medical history who presented with a left vertebral dissection and basilar artery thrombus. #LEFT VERTEBRAL ARTERY DISSECTION #BASILAR ARTERY THROMBUS #CEREBELLAR INFARCTS He initially presented with acute onset nausea and dizziness, found to have a left vertebral artery dissection and basilar artery thrombus. He was started on a heparin gtt. He was admitted to the neuro ICU for frequent neurochecks, but remained neurologically intact. An MRI was performed that showed bilateral scattered infarcts in the cerebellum. He was transitioned to lovenox from heparin and was started on warfarin on ___. He was then transferred to the ___. In the NIMU, he was monitored closely (remaining normotensive during his NIMU course). He had only one episode on ___ when he had symptoms including nausea, dizziness, vertigo, tinnitus after exertion that were referable to the brainstem, possibly related to overexertion and inadequate hydration. He was encouraged to increase PO fluid intake and did not require additional fluids or PRN antihypertensives. He was started on atorvastatin 80mg daily and continued on warfarin except for 2 days (___) when his warfarin doses had to be held for a supratherapeutic INR of 4.2. He was given education on restrictions related to his dissection prior to discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. A fluid collection within the cholecystectomy bed is re-demonstrated, better assessed on prior CT from earlier today. 2. Hepatic steatosis. The patient was diagnosed with Unspecified abdominal pain, Type 2 diabetes mellitus without complications. The patient was treated with N. At the time of discharge, the patient had Post-operative pain, status-post open cholecystectomy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ was admitted to ___ on ___ for pain control and evaluation of imaging studies obtained at an OSH concerning for biloma in the setting of her recent open cholecyctectomy. On review of the imaging studies with several surgeons and radiologists, it was determined that the fluid collection on the outside hospital CT scan was a small fluid collection consistent with normal post-operative changes. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ ESRD ___ HD, HTN, IDDM currently on INH for tx of latent TB, presenting from ___ clinic due to worsening dyspnea along with progressive cough and overall malaise. He first met new PCP ___ ___ at which time he complained of a cough for at least 6 months duration. Prior to that visit, he had a positive PPD and had AFB smears x3 in ___ which were negative. He endorsed 15lb weight loss and hempoptysis. He was referred to ID and saw them on ___ -> initiated on isoniazid +B6 for 9 months for latent TB treatment. Since that time patient denies any interval improvement in symptoms, and rather his cough is maybe worse. Day of arrival he was seen in the ___ clinic where patient noted chest tightness and cough productive of thick yellow sputum. His BP was 198/100 in the clinic, with 92% SaO2. In the ED, initial vitals were 98.6 86 197/97 16 96% RA Labs notable for K 6.0. Patient received levaquin and ceftriaxone Prior to transfer 98.3 82 176/105 14 98% RA On the floor, he denies any fevers or night sweats but notes some chills. He notes minimal increase in peripheral edema. Notes epigastric pain worse with laying flat or food sometimes. Also notes lose stools and nause+emesis that is chronic for about ___ mo. Emesis caused by eating too much food. No pain with food/water. Last significant emesis during ___. Malaise along with current constant cough really bad in last 4 weeks. Wants to try crackers CHEST RADIOGRAPH ___ showed Bilateral hilar opacities likely reflect moderate pulmonary edema. Cardiomegaly is stable. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN. At the time of discharge, the patient had PRIMARY DIAGNOSES: #Chronic cough #Pulmonary edema #End stage renal disease #Hypertensive urgency #Diabetes ___ type 2, poorly controlled #Dyspepsia #SECONDARY DIAGNOSES: #Latent tuberculosis infection #Anemia of chronic kidney disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo homeless M with LTBI on INH, ESRD on HD TTS, HTN c/b LVH, poorly controlled DM2, and childhood asthma presenting with subacute on chronic cough x ~10 months, early satiety with N+V x ~9 months, and loose stools ~7 months. #Subacute on Chronic Cough: Patient was initially admitted for a question of a health care associated pneumonia, and was started on clindamycin and ceftriaxone initially. This decision was based on a CXR that demonstrated pulmonary edema, with a pectus deformity causing appearance of RLL consolidation. However, given absent hypoxemia, fever, leukocytosis it is unlikely that he has a bacterial pneumonia (HCAP) and as such the antibiotics were discontinued on hospital day 1. We think the subacute component of his cough could represent worsening of a chronic problem such as hypervolemia with pulmonary edema, chronic asthma, GERD, or possibly subacute infection with atypical organism. That said, his estimated dry weight per HD is <300 lbs, though he has consistently been above 305 lbs at all outpatient visits since late ___, which may suggest that he never fully gets his lungs dry. Of note, he frequently asks to stop HD sessions ___ minutes early, so he never reaches his goal ultrafiltration or estimated dry weight of ~297 lbs. Given that he had childhood asthma that required overnight hospitalizations, with his last asthma attack in his late adolescence, it is possible that this is secondary asthma. Given that albuterol provided temporary abatement of symptoms, we started asthma treatment with fluticasone in addition to albuterol. PFTs may be considered in the outpatient setting. A multimodal approach aimed at allergic post-nasal drip, GERD, and asthma seemed reasonable. As such, he was given: albuterol ___ puffs q6h standing, fluticasone 110 mcg 2 puffs daily, loratadine 10MG every other day (HD dosing). If he does not show symptomatic improvement, then further workup is warranted, but the new medications such as PPI, fluticasone, and loratidine should be discontinued. #Early satiety w/dyspepsia/nausea/emesis: Notably he does not describe dysphagia or odynophagia to liquids or solids. GERD symptoms are not prominent, though occasionally he has epigastric discomfort. Gastroparesis is certainly possible given poorly controlled diabetes. Consider possible gastric emptying study vs possible EGD as an outpatient to further evaluate. #Possible GERD: continue home omeprazole dose. #Loose stools: Per patient, ___ bowel movements per day x 10 months. Painless, without nocturnal symptoms. His weight has been relatively stable x9 months despite reported weight loss. Patient later endorsed soft stool (not loose/watery). He did not show evidence of diarrhea during his admission. #Latent TB: Continued daily isoniazid treatment with pyridoxine inpatient. Of note, patient endorses forgetting about half of his isoniazid pills. LFTs normal. Recommend avoidance of quinolones/macrolides therapy in treating future infections in order to avoid possibility of resistant tuberculosis. Arranged follow-up Dr. ___ in one month for his LTBI therapy, appointment pending at discharge. #Hypertensive Urgency: BPs 170s-200s in clinic, maintained 170's-200's/90's-100's inpatient despite hemodialysis and home medications given. His BPs were somewhat improved after giving his home medications. #Diabetes ___, type II: Hb A1c 10.6 in ___. On Lantus and humalog insulin at home, though patient endorses not having regular access to a refrigerator for his insulin. Inpatient was on Glargine at 20 U qAM (25U qAM at home) with Humalog meal time. A HgA1C was obtained and was 9.7% at the time of discharge. #ESRD on HD: ___ via LUE AVF. Last HD ___, then ___. Patient endorses missing ~1 HD session per month, and also has not been receiving full HD sessions secondary to headache towards end. Had pulmonary edema on admission CXR. Dry wt estimated to be ~295 (135 kg). Patient was counseled to try and get the full HD sessions. Continued nephrocaps, sevelamer, cholecalciferol, and renal diet while inpatient. Will continue regular dialysis schedule outpatient. #Anemia of CKD: Hgb ~10, at baseline. Provided EPO 6000 Units qHD and Venofer 100 mg qHD </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history of medically refractory torsion dystonia s/p DBS placement in ___ most recently s/p battery change ___ ___. She presents with complaints of increased pain and fever. She was febrile to 101 two nights prior to admission. She initially thought she had the flu, but noticed her IPG site was swollen. She was referred to the ED for evaluation. A collection was tapped in the ED which was concerning for purulent drainage. She was taken to the OR for a wound washout and removal of her stimulator and extension leads to the level of occiput. CHEST (PA AND LAT) showed 1. Tiny bilateral pleural effusions. 2. No focal consolidation to suggest pneumonia. SKULL, ___ VIEWS showed 1.5 cm curvilinear density overlying the parietal region is suspicious for retained lead fragment. The finding is not well visualized on frontal view, but likely located in the left parietal region, external to the cranium. NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 9:39 am, 15 minutes after discovery of the findings. CHEST (SINGLE VIEW) showed Compared to chest radiographs ___ and ___. Left pectoral generator and ascending leads have been removed since ___. Aside from a row of skin staples, there are no visible retained metal fragments. No pneumothorax or pleural effusion. Lungs clear. Heart size normal. Dilated upper lobe vessels suggest mild volume overload. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed A left chest wall fluid collection/abscess measures up to 7.6 cm. With a surgical drain is located along the collapsed superior portion . No evidence of infection along the stimulator tract in the subcutaneous soft tissues of the neck. The patient was diagnosed with Fever, unspecified. The patient was treated with Removal of L DBS battery and debridement, removal of L extension cable. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with a history of medically refractory torsion dystonia s/p DBS placement in ___ most recently s/p battery change ___ ___ presented to the ED with complaints of increased pain and fever. She was febrile to 101 two nights prior to admission. A collection was tapped in the ED which was concerning for purulent drainage from the L IPG site. She was taken to the OR for a wound washout and removal of her stimulator and extension leads to the level of occiput. She was then transferred to the floor for further management. #Infected hardware s/p IPG removal Ms. ___ underwent neuro checks every 4 hours on the floor after returning from the operating room. Skull X-ray demonstrated a small retained fragment, while neck CT demonstrated no retained fragments and a small chest wall abscess. ___ was consulted for drainage of this abscess, but stated that the abscess was too small to drain and it would be better for her to follow up with additional imaging as an outpatient to assess for resolution. Infectious disease was consulted and Ms. ___ was started on Vancomycin and Ceftriaxone. Ceftriaxone was discontinued on POD2, and Vancomycin was discontinued and replaced with Bactrim on POD3. She will complete a four week course of Bactrim as an outpatient and will follow up with ID ___ weeks after discharge for an ultrasound of the chest wall and to assess antibiotic plans. Wound cultures grew out coagulase positive staphylococcus, while blood cultures did not grow out organisms. #DYT1 Dystonia Neurology was consulted for management of dystonia. They discussed the possibility of outpatient botox injections with the patient, to which she was amenable. Should this not alleviate her symptoms, she was given a prescription for Baclofen to be taken at night PRN. Notably, she will have to stop breastfeeding if she takes the Baclofen, and this was communicated to her. Neurology will be calling her to coordinate outpatient follow up. At the time of discharge, Ms. ___ was ambulating independently and was afebrile. She was instructed to follow-up for any symptoms concerning for returning infection.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old male presenting with 1 day history of left flank pain and dysuria. Upon further work up, he was found to have a 5 mm left UVJ stone and 1.9 cm proximal right ureteral stone. He has a history of kidney stones in the past which he passed spontaneously. He has never required surgery for stones. He is afebrile and hemodynamically stable. WBC 11. Cr 1.5. U/A negative for infection. Radiology showed Residual contrast within the bilateral renal collecting systems with note of bilateral hydronephrosis, right greater than left. Known stone re-demonstrated within the right UPJ. Known left distal ureteral stone not clearly seen. Intraoperative fluoroscopy, abdomen. showed Ongoing bilateral retrograde ureteral stent placement in the operating room. Please refer to the operative note if needed for further information. CTU (ABD/PEL) W/CONTRAST showed 1. Moderate to severe right hydronephrosis secondary to 1.9 cm obstructing stone in the proximal right ureter. No definite perinephric abnormality. 2. Mild left hydronephrosis secondary to a 5 mm stone seen in the distal left ureter immediately proximal to the UVJ. Mild left perinephric and left periureteral stranding. 3. Hepatic steatosis. The patient was diagnosed with Hydronephrosis with renal and ureteral calculous obstruction. The patient was treated with Cystoscopy, left ureteroscopy, laser lithotripsy, and bilateral ureteral stent placement.. At the time of discharge, the patient had Bilateral ureterolithiasis. acute kidney injury (creatinine up to 1.7). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted Dr. ___ service for nephrolithiasis management with known bilateral ureteral stone and taken urgently to the operative theatre where he underwent cystoscopy, left ureteroscopy, laser lithotripsy, and bilateral ureteral stent placement. He tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. Intravenous fluids and Flomax were given to help facilitate passage of stones. At discharge on POD1, patient’s pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. His labs were checked and he was advised to follow up as directed. He was was explicitly advised to follow up as directed as the indwelling ureteral stent must be removed on the left and he will still need definitive stone management on the right. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female professor at ___ with no known psychiatric history who was brought in by NEU security for erratic behavior. History largely taken from psychiatric consult note and ED notes as pt is somnolent and uncooperative with interview upon arrival to floor. Psych consult spoke with close work friend ___ and ___ roommate ___ who both confirmed various details of her history. Pt has had increasing psychosocial stressors at work and in family. Grandmother recently passed. Also had increasing stress at work. . In the ED, initial VS: 97.6 95 129/91 20 100%. During interview with psychiatry, pt became agitated, screaming loudly. She received haldol 5mg x 2 IM and ativan 2mg x 2 IM and placed in 4 point soft restraints. Following administration of haldol and ativan, pt became tachycardic to the 130s. EKG showed sinus tachycardia. HR decreased to 110s after IV fluids but then increased to 160s again. Toxicology consult was obtained; felt that tachycardia could be due to anticholinergic effects of haldol or paradoxical rxn to ativan. Recommended discontinuation of haldol and liberalization of ativan for agitation. . Currently, pt is extremely lethargic and somnolent. Awakens to loud voice and sternal rub but quickly falls back asleep. . REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed 1. Several small scattered FLAIR hyperintense foci in the cerebral white matter in the frontal and the parietal lobes predominantly, without associated enhancement. These are nonspecific in appearance and can be seen with small vessel ischemic changes, post-inflammatory sequela, post-infectious sequela,vasculitis type of disorders or less likely demyelinating disease given the appearance and distribution. As no prior studies are available, a followup can be considered in a few weeks or earlier as clinically necessary, to assess stability/progression after correlation clinically and with labs to assess underlying risk factors. 2. No focal abnormal enhancing lesions noted. Radiology showed No evidence of acute intracranial process. The patient was diagnosed with ALTERED MENTAL STATUS , TACHYCARDIA NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Psychosis, NOS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># Psychosis: Patient with no psychiatric history presented with what seemed to be first psychotic break in setting of increasing psychosocial stressors. Serum and urine toxin screen was negative, arguing against substance-related mania. The patient was admitted to medicine to rule out organic causes of psychosis. Work-up included Head CT, head MRI, TSH, HIV serology, serum coritisol, infectious work-up, and liver function tests. The patient was also empirically started on IV acyclovir out of concern that she may have an underlying HSV encephalitis. Neurology was consulted for the concern of an encephalitis that was the cause of her symptoms. Neurology was thought that the patient's symptoms were more consistent with a psyhciatric diagnosis and recommended getting a brain MRI as well as serum ___ and ___ and ___ were pending on day of discharge. All other work-up proved to be negative. The patient was followed by psychiatry throughout the admission. She was started on 2.5mg haldol twice daily. On day of discharge, psychiatry deemed that there were no psychiatric contraindication to discharge home with her mother. The patient was scheduled for an appointment at ___ Partial Hospitalization Program- ___., ___. ___ at 9am. The patient was discharged on haldol 2.5 mg PO BID. The patient and the patient's mother agreed to return to the ED or call ___ should symptoms worsen again or she experiences any SI/HI. Mother is to remain with patient after discharge to monitor symptoms and assist with getting her to treatment. OUTPATIENT ISSUES: Continuation of haldol 2.5mg twice daily. Follow-up at ___ Partial Hospitalization Program- ___., ___. ___ at 9am. . # Abnormal Head MRI: Several small scattered FLAIR hyperintense foci in the cerebral white matter in the frontal and the parietal lobes predominantly, without associated enhancement were noted on head MRI. Per radiology, these are nonspecific in appearance and can be seen with small vessel ischemic changes, post-inflammatory sequela, post-infectious sequela,vasculitis type of disorders or less likely demyelinating disease given the appearance and distribution. Neurology recommended that this by followed-up by neurology on an outpatient basis. Given the holiday weekend, a follow-up appointment could not be arranged. However, the patient was given the telephone number to contact the neurology office for an appointment for within two weeks from discharge date. OUTPATIENT ISSUES: Follow-up on an outpatient basis with neurology regarding hyperintensities noted on Head MRI. Follow-up of pending ___ and ___ that was obtained as part of neurology work-up. ___ was positive at 1:160, cerruloplasm normal range at 26 . # Hematuria: Patient was noted to have hematuria on a urine analysis on admission. Urine culture was drawn that showed mixed bacterial flora consistent with contamination. A repeat urine analysis did not show blood. . # Tachycardia: Patient with episodes of tachycardia, heart rate ranging 110s to 160s in the emergency department. EKGs showing sinus tachycardia. Heart rate increased with agitation/activity and was in the low 100s while sleeping on morning of admission. Given onset of tachycardia following ativan/haldol administration, toxicology consult obtained who suggested tachycardia could be secondary to anticholinergic effect of haldol or paradoxical reaction to ativan. The patient's heart rate trended down through the admission. The patient was challenged with oral haldol and had no other rebound tachycardia. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female who is known to the neurosurgery department, a patient of Dr. ___ with a known brainstem cavernous malformation who called the neurosurgery office earlier today with complaints of LUE weakness and ataxia. Patient was instructed to go to the nearest ED, while at OSH ___ negative for acute new hemorrhage. Patient requested transfer to ___ as she is followed closely by Dr. ___. On presentation to the ED neurosurgery was consulted. On exam, patient lying in stretcher in NAD. Patient states that she noticed today her gait was off balance and she was having difficulty writing with her left arm that was getting progressively worse. Patient states that she has an occipital pressure and headache however states this is common for her. She denies visual changes, nausea, vomiting, lightheadedness, dizziness, bowel or bladder complaints or any other complaints. Patient does endorse tingling in her fingertips which she states has been present since prior CVAs. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed Medullary lesion is consistent with cavernous malformation with interval increase in T2/FLAIR signal abnormality, likely representing increased evolving blood products. The patient was diagnosed with Weakness, Unsteadiness on feet. At the time of discharge, the patient had Brain stem cavernous malformation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ was admitted to the ___ for monitoring and observation out of concern for possible rehemorrhage of her known brain stem cavernous malformation. MRI was performed which showed no significant hemorrhage, but increased local edema and evolution of blood products. She was given a 10mg dose of IV dexamethasone, and started on a one week dexamethasone taper. #Disposition ___ evaluated her and determined she was at her baseline, had an adequate support system, and had strategies in place to make a home discharge safe. She was discharged home with plans for the clinic to contact her for close outpatient follow-up.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/op COPD, alcohol abuse, and ___ transferred from ___ after being brought to their ED with EtOH on board after an assault. He was in some type of altercation and walked into a fire station early AM ___ from which he was brought to an OSH. He was noted to have multiple facial lacerations and ongoing pharyngeal bleeding. A head CT was negative for neural injuries but revealed bilateral mandibular fractures and a nasal fracture. He was intubated for airway protection given that he was bleeding and transferred to ___ for further management. Chest radiograph. showed 1. Study was re-read once outside hospital CT scan was uploaded and apparent mediastinal widening is due to abundant mediastinal fat. 2. Although no fracture or other bone abnormality is seen, conventional chest radiographs are not appropriate for detection or characterization of chest cage lesions. Any focal findings should be clearly marked and imaged with either bone detail views or CT scanning. MRA BRAIN AND NECK showed No evidence of dissection or occlusion involving the head and neck vessels. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST showed 1. Status post open reduction and internal fixation of multiple anterior mandibular fractures. No evidence of hardware failure. 2. Extensive, acute on chronic, multifocal sinus disease, as above. CHEST (PORTABLE AP) showed Cardiac size is top-normal. Mediastinal contours are unchanged. ET tube is in standard position. NG tube tip is out of view below the diaphragm. There are low lung volumes with bibasilar atelectasis. There is mild vascular congestion. Retrocardiac opacities have increased likely atelectasis. There is no evident pneumothorax. Skin staples and hardware material in the mandible are noted CHEST (PORTABLE AP) showed In comparison with study of ___, the patient has taken a better inspiration. There is now a bibasilar opacification consistent with a combination of atelectatic changes and pleural effusions. Monitoring and support devices are unchanged. Continued enlargement of the cardiac silhouette, but no definite vascular congestion or acute focal pneumonia. PORTABLE ABDOMEN showed 1. Nonspecific bowel-gas pattern. 2. Nasogastric tube in appropriate position. The patient was diagnosed with FX SYMPHY MANDIB BDY-OPN, NASAL BONE FX-CLOSED, UNARMED FIGHT OR BRAWL, OPEN WOUND OF JAW. The patient was treated with ___ fixation, bilateral mandible fracture. At the time of discharge, the patient had S/p assault. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___: The patient was involved in an altercation and and incurred bilateral mandible fractures and nasal fractures. He was intubated at an OSH for bleeding, and was transferred to ___ and admitted to ___. Plan per OMFS was for repair on ___. He did spike a fever to 101.6, and was given tylenol, and blood/urine cx were sent. Due to his history of ETOH, he was given Ativan at that time, and was started on ___ ___: Vent was weaned to CPAP, and he was off all sedation. RISBI was 22, so he was extubated. He was switched to a Phenobarb protocol from CIWA scale (Ativan). His C-collar was cleared at that time, SQH was started and he was made NPO at midnight in preparation for OR with OMFS on ___. ___: Pt nasotracheally intubated. He underwent fixation of right subcondylar mandible fractures, extraction of teeth # 24,25,26,27, closed reduction of mandibular alveolar fracture, repair of chin laceration. ___: He underwent a seizure post OR that was managed with just Phenobarb taper. His HCT dropped from 27 to 19.5, and he was transfused 1 unit of blood. He was febrile to 100.5, he had blood clots suctioned from the oral cavity. JP R neck had 145 CC serosanguinous output, and JP L had 25 CC serosanguinous output. ___: He was extubated. The patient pulled his NGT and foley was d/c'd. He was again febrile to 100.1. JP R had 20 CC serosanguinous output, JP L had 10 CC serosanguinous output. No other events. He continued on his Phenobarb taper. He was voiding without difficulty. ___: He continued on his Phenobarb taper. No acute events overnight. Pt was transferred to the floor. ___: JP drains were removed. Rehabiliation process started. The patient continued on Phenobarbital taper, no further evidence of sz. activity. The patient was tolerating a full liquid diet, he was ambulatory. ___: The patient was discharged to the ___ ___ in stable condition. Phenobarb d/c., prescription for pain meds was given. A follow-up appointment was made with the ___ service. Social worker met with patient and addressed out-reach programs. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ s/p stab to L flank, R trapezius, and R anteromedial neck w/likely old L carotid dissection found on CTA. Patient's brother stabbed him multiple times. Was intoxicated at the time. No respiratory distress, no difficulty swallowing, conversant, no difficulty speaking. No chest or abdominal pain. Neuro exam intact. No numbness/tingling. Was transferred here from ___ for further evaluation. CT head was negative. CTA neck showed air tracking along the right neck stab wound towards the left side of the neck, ending a few centimeters below the area of the left carotid dissection. The dissection itself is 1cm superior to the carotid bifurcation in the ICA, extending for about 5mm. Patient is asymptomatic, no focal neurologic findings. Does have a history of previous L-sided blunt trauma resulting in a mandibular fracture. Radiology showed 1) No acute pulmonary process identified. 2) Ununited left clavicular fracture that is thought to be old. Osteoarthritis in the left glenohumeral joint. Radiology showed There is dissection of the left internal carotid artery with a small pseudoaneurysm as described in detail above. Subcutaneus emphysema tracking along the anterior neck tissue plane. Apparently, there is no evidence of active contrast extravasation. These findings were discovered and communicated via phone call to Dr. ___ by Dr. ___ at 5:15 a.m. on ___. Radiology showed 1. No evidence of acute intra-abdominal injury. Findings suggesting superficial right posterior injury. 2. Splenomegaly, mildy prominent celiac lymph nodes, and findings suggesting esophageal varices. No clear morphological changes in the liver; however, findings are concerning for liver disease with portal hypertension. 3. The left hip appears to be externally rotated. This may simply be due to positioning; however, injury is not excluded. Correlation with physical exam findings is recommended. Radiology showed No acute intracranial process. Radiology showed Bilateral less than 40% carotid stenosis with minimal plaque. There is no evidence of carotid dissection bilaterally in the visualized portion of the carotid arteries. The patient was diagnosed with OPEN WOUND OF NECK NEC, OPN WND LATERAL ABDOMEN, OPEN WOUND OF BACK, FX CLAVICLE NOS-CLOSED, ASSAULT-CUTTING INSTR, DISSECTION OF CAROTID ARTERY, ALCOHOL ABUSE-UNSPEC. At the time of discharge, the patient had Multiple stab wounds. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Pt was admitted to trauma surgery service on ___. Vascular surgery consulted for evaulation of stab wounds with possible involvment of carotid artery. He was monitored closely. Received appropriate pain control. Social work consulted for substance use and safety of home environment. On repeat duplex ultrasound ___, there were no defects to the carotid. He was discharged home on ___ with aspirin. No focal neuro deficits on exam. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH of advanced dementia, systolic CHF (EF35%) ___ ischemic CM, s/p bioprothestic MVR, atrial fibrillation on xarelto, h/o VT/VF and AF s/p AVJ ablation s/p BiV ICD, PVD s/p L external iliac to femoral bypass presenting for evaluation of slowly progressive decline in his mental status particularly over the last week. ELBOW (AP, LAT AND OBLIQUE) RIGHT showed No comparison. Three views of the right elbow are provided. Parts of a venous access device are visualized in the cubital fossa and projecting over the joint. No other soft tissue abnormalities. No evidence of fracture or dislocation. No erosions. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality. 2. Large area of encephalomalacia involving the right posterior temporoparietal lobes is unchanged from ___. CT C-SPINE W/O CONTRAST showed No cervical spine fracture or malalignment. CT ABDOMEN PELVIS WITHOUT CONTRAST showed 1. No acute findings in the abdomen or pelvis.No acute fracture. 2. Large stool ball in the rectum. CHEST RADIOGRAPHS showed No pneumonia. The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had Acute metabolic Encephalopathy Constipation Acute kidney injury secondary to Dehydration Chronic Systolic CHF Dementia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old male with past medical history of dementia, systolic CHF, bioprothestic MVR, atrial fibrillation on xarelto, history of VT/VF, atrial fibrillation, peripheral vascular disease, admitted with metabolic encephalopathy, dehydration and constipation, now renal function and mental status back to baseline, able to be discharged to rehab # Nausea/vomiting # Contipation: Patient's son described decreased PO intake within the 2 days prior to presentation as well as a few episodes of non-bloody, non-bilious emesis. A CT A/P was done in the ED which showed a large stool ball and no other acute findings. He was treated with an aggressive bowel regimen and had bowel movements with improvement in his nausea. He had no episodes of emesis and was able to tolerate a diet and maintain his nutritional and hydration status. Started and continued miralax at discharge. # Acute kidney injury: Baseline Cr around 1 but was 1.8 on admission. Likely prerenal in the setting of poor PO intake secondary to nausea and constipation. Resolved to baseline with IV fluids. . # Acute metabolic Encephalopathy # Dementia with behavioral disturbance Patient with baseline severe dementia admitted with lethargy in the setting of dehydration and ___ as above. After IV fluids and moving bowels his mental status improved to his baseline per his son. At baseline, he was non-lethargic, alert and oriented to self only but calm and answered questions appropriately. An infectious work up for other causes of encephalopathy was done and was unremarkable. TSH and B12 were unremarkable. # Gait instability: # Fall: Patient's son described more instability with walking and falls. A trauma work up including CT head was negative. ___ assessed the patient and recommended discharge to rehab. B12, TSH, and SPEP were sent and were normal. # Dysphagia Evaluated by speech and swallow with recommendation for pureed solids and thin liquids. # Chronic Systolic CHF Initially dehydrated as above. Continued Labetalol. Of note, has not been maintained on metoprolol or lisinopril for unclear reasons. If consistent with goals of care, would consider starting. Per report from his facility, he is no longer on a diuretic. Once taking PO, he remained euvolemic without the need for diuresis this admission. # Afib # History of VT/VF Patient continued on rivaroxaban # Dementia Discontinued Seroquel given initial encephalopathy. Course notable for absence of agitated, behavioral disturbance or other indication for this medication. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is ___ ___ yo current smoker who has had minimal past medical care. On ___ she presented to an outside hosptal with intermittent SSCP which was worse with exertion. She presented with hypertension, SBP>200 and frothy pink sputum. She was given lasix and lisinopril. She ruled in for a NSTEMI, and was taken for cardiac cath, report not in chart but per report ___, 100%LCx,90%oRCA, 90%mRCA. Radiology showed Findings as stated above which indicate: 1. No significant right ICA or CCA stenosis. 2. Approximately 40% left ICA stenosis. Radiology showed Anticipated post-operative findings. Radiology showed Increased right-sided pleural effusion with adjacent atelectasis. Improved left-sided atelectasis with persistent and unchanged left pleural effusion. Radiology showed Stably enlarged cardiac contours status post median sternotomy with mitral valve annular ring and CABG. There is persistent bibasilar patchy opacity with likely associated small effusions. These findings may reflect compressive atelectasis, although aspiration or pneumonia should also be considered. No evidence of pulmonary edema. No pneumothorax. Overall, the appearance is not significantly changed since ___. Radiology showed Unchanged probable basilar atelectasis and effusions, moderate on the left and small on the right. The patient was diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE, HYPERCHOLESTEROLEMIA. The patient was treated with ___ 1. Urgent coronary artery bypass graft x3; left internal mammary artery to left anterior descending artery, and saphenous vein graft to ramus and posterior descending arteries. 2. Mitral valve replacement with a 27 mm ___ mechanical valve.. At the time of discharge, the patient had - Myocardial infarction, coronary artery disease s/p coronary artery bypass graft x 3 - Mitral valve regurgitation s/p Mitral valve replacement - Acute systolic Congestive heart failure Past medical history: - Obesity - Hypertension - Peripheral arterial disease - COPD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ was transferred from outside hospital with a myocardial infarction and cardiac cath that revealed severe three vessel coronary artery disease. Upon admission she was medically managed and underwent appropriate work-up prior to surgery. On ___ she was brought to the operating room where she underwent 1. Urgent coronary artery bypass graft x3; left internal mammary artery to left anterior descending artery, and saphenous vein graft to ramus and posterior descending arteries. Mitral valve replacement with a 27 mm ___ mechanical valve. The cardiopulmonary bypass time was 168 minutes with a cross clamp of 141 minutes. She tolerated the operation well and following surgery he was transferred to the CVICU for invasive monitoring in stable condition. She remained hemodynamically stable, sedation was weaned, awoke neurologically intact and was extubated. All other tubes, lines and drains were removed per cardiac surgery protocol without complication. She was started on Beta-blockers, diuretics and these were titrated as needed. On POD1 she was transferred from the ICU to the stepdown floor for continued recovery. Chest tubes and pacing wires were discontinued without complication. Heparin bridge was started with coumadin on POD2 for her mechanical valve, INR goal 2.5-3.5. She received a course of Keflex for erythema at ___ site. She was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 12 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with ___ in good condition with appropriate follow up instructions.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ male who presents to the emergency room today for right leg pain. The patient was climbing over a fence last night and had a fall resulting in injury to the right leg. The patient was seen at outside hospital where he was found to have a midshaft fibular fracture and a medial and posterior malleolus fracture. The patient denies any other injury. He says the pain is increasing. He took approximately 3 oxycodone around noon today prior to our evaluation. He denies any numbness or tingling in the foot. PMH: none MED: none ALL: nkda SH: Denies any etoh, tobacco or illicit drug use PE: A&O x 3 Calm in mild discomfort Chest: ctab Abd: soft, non tender RLE skin clean and intact Significant swelling, ecchymosis noted in the distal leg especially around the medial malleolus and into the foot The anterior compartment is somewhat tense, posterior compartment is soft No pain with passive motion of the toes, there is pain with passive dorsi and plantar flexion Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ FHS ___ TA Peroneals Fire 1+ ___ and DP pulses LABS: Laboratory data was reviewed and notable for normal coagulation profile, hct 45 IMAGING: Plain films were reviewed and notable for right midshaft fibula fracture, medial and posterior malleolus fracture Radiology showed Minimally displaced bimalleolar fracture with probable improved alignment of the ankle mortise post closed reduction. The patient was diagnosed with FX MEDIAL MALLEOLUS-CLOS, UNSPECIFIED FALL, FX SHAFT FIBULA-CLOSED. The patient was treated with closed reduction under anathesia, right ankle. At the time of discharge, the patient had Right ankle fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the Orthopedic service on ___ for a right ankle fracture. On ___ he underwent closed reduction and cast application under anesthesia without complication. His pain was controlled with PO oxycodone, tylenol and IV morphine. On HD3 he cleared physical therapy and was medically stable for discharge. He will follow up in 2 weeks to assess swelling of ankle and possible surgical intervention at this time.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o woman with PMH notable for NASH cirrhosis c/b recurrent admissions for HE and grade 2 varices s/p banding, GAVE s/p APC in ___, HFpEF, HTN, and T2DM, presenting with 3 days of worsening weakness. Radiology showed No acute cardiopulmonary process. Interval vertebral body height loss at T12 since ___, to be correlated with physical exam as acuity cannot be determined. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Hepatic cirrhosis without focal lesion. Patent hepatic vasculature. 2. Cholelithiasis without evidence for acute cholecystitis. The patient was diagnosed with Hepatic failure, unspecified without coma, Urinary tract infection, site not specified, Altered mental status, unspecified. At the time of discharge, the patient had Primary diagnosis: Rhabdomyolysis Urinary tract infection Toxic metabolic encephalopathy Hepatic encephalopathy Secondary Chronic diastolic heart failure Diabetes mellitus Pyoderma gangrenosusm. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o woman with a PMH notable for NASH cirrhosis c/b recurrent HE, GAVE s/p APC, PG, and brittle T2DM, presenting with acute onset b/l ___ weakness and pain (in proximal distribution) in setting of chronic weakness and labs notable for transaminitis and CK >7000 and UTI now with CK and LFT downtrending after fluid resuscitation. It is likely she developed rhabdomyelisis in the setting of acute confusion caused by the UTI. With volume resuscitation and treatment of the UTI, her symptoms improved. #Rhabdomyolysis, weakness: The patient's elevated CK >7000 on admission. AST and ALT elevation are likely in [large] part due to rhabdo as well. Likely etiology of immobility at home in setting of acute confusion due to UTI. Drug-mediated causes also possible including atorvastatin as potential trigger and statin was held. No crush injuries or compartment syndrome suspected based on history or exam. Inflammatory etiology investigated but inflammatory makers low-normal at CRP 10.5, ESR 31 not suggestive of PMR. She was given 500cc NS, 50g 25% albumin, and total 50g 5% albumin during her hospital course in increments of 12.5g. CK trended down with level at discharge 124. Physical therapy evaluated the patient and recommended rehab. #UTI: Patient has positive blood and WBCs on U/A. History of UTI and three days of confusion coming in may be reflection of infection. She received 1 dose of Ceftriaxone in ED empirically. Urine culture grew mixed bacterial flora. History of Klebsiella oxytoca infection in ___ sensitive only to cipro, ___, zosyn. E. coli resistant to cipro noted in ___. She was started on ciprofloxacin 500mg Q12H on ___ with planned 7 day course; however urine cultures came back as Enterococcus with multiple resistances (Including cipro) and sensitive to doxycycline. We therefore started doxycycline 100mg daily for 7 days (end date ___ #Transaminitis: Attributed to rhabdo with normal bilirubin with labs remaining at baseline synthetic hepatic function would suggest non-liver etiology. #Metabolic and hepatic encephalopathy: Likely secondary to UTI and reduced bowel movements prior to admission. Improved with fluid resuscitation, continuing lactulose and rifaximin, and treatment of UTI. She was at baseline on HD #2. #NASH cirrhosis: History of NASH cirrhosis c/b HE and GE varices and GAVE s/p APC in ___. Appears compensated at this time. She was continue on home PPI, nadolol, nutritional supplements. #HFpEF: Currently euvolemic appearing. ___ edema is likely due to local inflammation and slight hypoalbuminemia. -holding diuretic as above, I/s/o potential rhabdo. Furosemide and spironolactone held with plan to restart at discharge. #Celiac disease: gluten-free diet #Hypertension: Held diuretics and continued home nadolol. #T2 Diabetes mellitus complicated by neuropathy: She was continued on home lantus, ISS, gabapentin. #HLP: holding home statin in the setting of transaminitis and elevated CK #Pyoderma gangrenosum/Venous stasis uclers: Per recent outpatient notes, patient is not on any oral therapy and is recently s/p 10 day course of PO Keflex for ___ cellulitis. She was given local wound care without signs of worsening or cellulitis. #Iron deficiency anemia: per patient she has anemia at baseline, treated with PO iron. #Depression: continued home sertraline TRANSITIONAL ISSUES ============== #NEW MEDICATIONS - Doxycycline #CHANGED MEDICATIONS - None #HELD MEDICATIONS - Atorvastatin was STOPPED [] Restart diuretics on discharge (held for elevated CK and elevated LFT during admission) [] Reassess if a lower dose of a statin or different lipid lowering regimen as CK and LFT improve [] Dermatology follow up for lower extremity ulcers is scheduled for ___ [] Urogynecology follow up is scheduled for ___ #CODE: Full (confirmed with patient and husband) #CONTACT: Husband - ___ ___ #DISCHARGE WEIGHT - 121 Pounds</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ year old woman with history of HTN, DM2, CKDV, gout who presents with 1 day of vaginal bleeding and several weeks of malaise and poor appetite. The vaginal bleeding started this morning. She's never had anything like this since going through menopause. It's small volume, but was concerning enough to her and her family to present to the ED. In terms of her fatigue and poor appetite, it has been occurring over the last several months, and she's been told by her PCP and nephrologist that it's likely secondary to her kidney disease. She notes that she can't taste food very well (not a metallic taste) and therefore doesn't feel like eating and so has been loosing weight. No change in bowel habits. She denies any chest pain, palpitations, shortness of breath, cough, wheeze. She also denies abdominal pain, abdominal distension or bloating. No fevers, chills, or nightsweats. In the ED: - initial vital signs: 98.4 100 169/82 18 99% RA - Exam notable for abdominal distension, guaiac negative stool. Vaginal exam with moderate ___ bloody discharge with some cervical changes, no tenderness to palpation. - Labs were significant for Creatinine 4.3 (baseline 4.1), BUN 74, bicarb 17, Mg 1.1, phos 4.9; mild leukocytosis 10.6, normocytic anemia H/H 8.5/26.2 (baseline 9.4/29.4) , MCV 89, plts 237, normal coags. LFTs with elevated alk phos 124 otherwise within normal limits. - UA showed few bacteria, 24 WBC, large leuks, small blood, 300 protein, negative ketones. - Imaging: Pelvic ultrasound showed: Heterogeneous endometrium with fluid in the endometrial canal. - OBGYN was consulted for vaginal bleeding who recommended outpatient endometrial biopsy for post-menopausal bleeding. - Vitals prior to transfer: 98.5 81 126/68 14 100% RA On arrival to the floor, pt has no complaints. Describes feeling tired, but no other complaints. PELVIS U.S., TRANSVAGINAL showed Heterogeneous, thickened endometrium with fluid in the endometrial canal. Ovaries are not visualized however there are no adnexal masses identified. No free fluid in the pelvis. RECOMMENDATION(S): In this postmenopausal patient with bleeding and thickened heterogeneous appearance of the endometrium, further correlation with endometrial sampling is recommended. The patient was diagnosed with Acute kidney failure, unspecified, Abnormal uterine and vaginal bleeding, unspecified. At the time of discharge, the patient had Postmenopausal bleeding. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman with history of HTN, DM2, CKD V (baseline Cr ___, gout presenting with acute episode of vaginal bleeding as well as several weeks of malaise and decreased appetite # Post Menopausal Bleeding: Concerning for malignancy given history of weight loss with associated bleeding, pelvic ultrasound with heterogeneous endometrium. Alternatively consider atrophic bleeding, especially given that decreased appetite may be secondary to renal disease. She will follow-up with outpatient GYN for endometrial biopsy. # Anemia: Patient with baseline normocytic anemia secondary to chronic disease and CKD, on procrit q5 weeks as outpatient. Baseline Hgb ___ down to 8.5 on admission. Most likely secondary to acute episode of vaginal bleeding, possible malignancy with post menopausal vaginal bleeding. # Weakness: No neurologic deficits on exam. Most likely secondary to CKD, although malignancy is also on the ddx. No signs/symptoms of depression. TSH normal. Patient has upcoming renal appointment with Dr. ___ to discuss initiation of RRT; no indication for inpatient renal consult at this time. # asymptomatic pyuria: WBCs in urine from ED without symptoms (other than very longstanding generalized weakness, which is more likely related to her renal disease), started on CTX unfortunately without urine culture. Given low level bacteria and asymptomatic nature, this was deemed unlikely to be a UTI her antbiotics were discontinued. Blood cultures remain no growth to date, but recommend a repeat urinalysis and culture with further w/u as necessary. (Discussed this by phone with Dr. ___ team at ___ on ___, and gave my phone number for any further follow up, since patient did not answer my call.) CHRONIC MEDICAL ISSUES: #CKDV: Creatinine at baseline ___. Patient met with nephrology nurse ___ discussing renal replacement therapy options, has not made decision per Atrius records. She was continued on calcitriol 0.25mcg three times/week, and Vit D3 ___ IU daily and started on sodium bicarbonate 650 mg BID for low bicarb and given lab slip to have electrolytes rechecked ___. # HTN: Normotensive in ED and on admission. Continue home metoprolol XL 25mg PO daily, amlodipine 5mg PO daily, and torsemide 10mg PO daily. # DM2: Continued home regimen lantus of 19 U QHS, ISS. Discharged home on home regimen with lantus, novolog scale and glipizide. # Glaucoma: Continued on home latanoprost 0.005% qhs and timolol 0.5% gel forming solution 1 gtt both eyes qAM # HLD: Continued on home atorvastatin 40 mg PO qhs # Gout: continued on home allopurinol ___ PO daily (stable dose with current renal function) # GERD: continued on home omeprazole 20 mg daily # Chronic pain: continued on home acetaminophen 325mg PO q4-6h prn pain TRANSITIONAL ISSUES: ================ -Patient to call and schedule appointment with gynecology on ___ for endometrial biopsy. -Started on sodium bicarbonate for low bicarb during admission. -Labs to be checked and sent to PCP ___ ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with PMH of afib on coumadin, diastolic heart failure, and known bradycardia (previously considered for pacemaker) who presents from home with AMS and ongoing bradycardia. Pt. has several admissions and evaluations leading up to this presentation that are summarized below: Radiology showed No evidence of acute cardiopulmonary disease. Radiology showed Stable areas of atrophy, encephalomalacia, and white matter disease. No evidence of acute process. MRI AND MRA BRAIN AND MRA NECK showed 1. No acute intracranial process. 2. Limited MRA due to patient motion. No high-grade stenosis or occlusion detected. The patient was diagnosed with CARDIAC DYSRHYTHMIAS NEC, ALTERED MENTAL STATUS . The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ with PMH of afib on coumadin, diastolic heart failure, and known bradycardia (previously considered for pacemaker) who presents from home with AMS and ongoing bradycardia. Pt. was witnessed to have several episodes of AMS that were not related to bradycardia. She had no events of hypoglycemia. Her TSH returned normal. Pt. noted to have ulceration of lip and oropharynx. Dermatology consulted thought may be ___ thrush +- HSV stomatitis. For thrush and evidence of vulvovaginitis, pt. given 2 doses of fluconazole with resolution of symptoms. She was without any other clear source of infection in addition to pan-negative culture data. Neurology evaluated the pt. and believed that her ___ Disease was likely not contributing to her AMS. Autonomic Neurology evaluated and thought her clinical situation may be consistent with ___ body dementia given her recent hallucinations, but it may also have been due to delirium. Overall pt's presentation was attributed to worsening dementia with likely ongoing hypoactive delirium ___ recent hospitalization, pain from oropharyngeal ulceration, and ongoing vulvovaginitis. Her mental status improved slightly with improved pain control and treatment of her vulvovaginitis. ACTIVE ISSUES ============== # Altered Mental Status: Pt. with waxing and waning mental status consistent with hypoactive delirium. Thought to be multifactorial with contributing factors including admission where new onset delirium was noted, significant constipation, vulvovaginits/thrush (in the setting of recent course of prednisone/azithro), and pain from healing oral mucosal ulcerations. Pt. initially presented with bradycardia which was not thought to be contributing factor as pt's mental status acutely worsened on different occasions during the hospitalization without evidence of bradycardia at that time. For concern of hypoperfusion, pt's blood pressure regimen was discontinued. Infectious work-up was sent including blood cultures, urine cultures, and CXR all which returned negative. Thyroid function was checked and TSH returned normal. Pt. was without evidence of hypoglycemia. For concern of worsening of her underlying dementia and ___ Disease, neurology and autonomics was consulted. An MRI Brain/Neck was done which revealed no acute intracranial process. Autonomics thought that her overall presentation may be consistent with ___ Body Dementia vs. Hypoactive Delirum. She remained somewhat somnolent with evidence of ongoing delirium and dementia at time of discharge. # Atrial Fibrillation with Slow Ventricular Rate: Pt. with evidence of atrial fibrilation with slow ventricular rate on admission. Per family, this has been well documented and investigated in the past. Per daughter, pacemaker had been considered prior. She also had evidence on admission of afib with RVR. This clinical picture suggests possible sick sinus syndrome. Pt. was thought to be asymptomatic from her bradycardia as she has had multiple episodes of AMS without bradycardia. Outpatient cards follow-up was arranged. # Vasovagal Presyncope: In AM ___, pt. had brief episode of hypotension and diaphoresis following straining episode and massive bowel movement. This was thought to be ___ vasovagal presyncope. Pt. was started on a bowel regimen without repeat episode. # Lip and Soft Palate Oral Mucosal Ulceration: Pt. presented recently with lip swelling/lip ulceration/ and palate ulceration which previously was thought to be a possible allergic reaction. Dermatology was consulted for evaluation and felt that pt's condition was most consistent with HSV stomatitis. Pt. was out of the treatment window for anti-virals. Various mouth care and lip care was enacted with viscous lidocaine, mupirocin, orabase, and nystatin swish and spit for possible thrush component. Pt's symptoms improved during hospitalization. # Blurry Vision: Pt. complained of worsening blurry vision. This was difficult to assess given pt's mental status. This was thought to be related to recent anticholinergic/cholinergic medications pt. had received recently. Case was discussed with ophthalmology who thought that given lack of conjunctival injection or drainage, unlikely infectious or other concerning etiology at this time. Pt was given saline eye drops and outpatient ophthalmology follow-up was recommended. # Vulvovaginitis: Pt. with evidence of white exudative vaginal discharge. Given recent course of prednisone and clinical presentation, her symptoms were thought ___ candidal vulvovaginitis. She was given 2 doses of fluconazole 150mg with resolution of symptoms. CHRONIC ISSUES ================== # ___ disease: Continued home Carbidopa-levodopa. # HTN: Continued on valsartan when SBP>110. Amlodipine was discontinued at discharge. # HFpEF: Continued lasix daily. # Atrial fibrillation: Stable. No rate control needed. Continued on warfarin. # GERD: Continued home PPI. TRANSITIONAL ISSUES ===================== # Goals of Care: Palliative Care saw pt. during hospitalization. Hospice was described. Pt. and family seem interested. Would continue to discuss code status, goals of care, and possible hospice transition as outpatient. # Blurry Vision: Pt. c/o blurry vision worsening recently. Discussed case with ___ on admission. No evidence of conjunctival injection or acute process requiring inpatient evaluation. They recommended outpatient follow-up. # Thrush: Pt. should continue on nystatin swish and spit until resolution of symptoms, no longer than 2 week duration. If symptoms persist, pt. should be evaluated. # Vulvovaginitis: Pt. given 2 doses of fluconazole with resolution of symptoms. If whitish vaginal discharge remains, pt. should be evaluated for further treatment. # Bradycardia: Likely sick sinus syndrome. Stable for several years per family. Would consider d/c'ing timolol as patients can have bradycardic effect on medication. # Autonomic Neurology Eval: Pt. seen by autonomics. Recommended to have SPEP/UPEP for further evaluation. ___ pending at discharge. # Hypertension: continued on valsartan, but amlodipine was discontinued given her BPs were low in 100-110s range on admission. Goal BP for her is between 130-160 systolic. # COPD: has used home O2, but here in the hospital was satting well on room air. Can continue to monitor saturations at home and use O2 as needed # CHF: will continue lasix 20mg daily and recommend following daily weights and sypmtoms (leg edema, shortness of breath) for further titration as an outpatient. # Macrocytic Anemia: B12 and folate return normal. Further work-up is recommended. # CODE: Full, confirmed but family will continue discussing this in the setting of her goals of care # CONTACT: ___ (daughter, HCP, ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old ___ speaking man with h/o ESRD (on HD ___, ESLD (s/p liver transplant ___, on cyclosporine), Afib (on ASA), T1DM, CAD, recent upper GIB (___) and previous subdural hematoma with neurologic deficits (___), recent admission ___, AMS and petechial rash, found to have sepsis with MRSA bacteremia. The most likely source of the patient's bacteremia was thought to be bacterial seeding through his HD graft during HD. By report from ___ patient has had a "change in mental status, refusing meds, meals, and fluids," for the past several days. On ___ patient pulled out tubing, dialysis session was unable to be finished. He is on cyclosporine for immunosuppression. Blood sugars 200s. Discussed with RN in ___ at ___, states the patient has been refusing any medications, food, has been intermittently agitated while getting IVs and dialysis. He has been very withdrawn and not speaking. Fall last week, fell on backside, no headstrike or LOC. The ED also had a discussion with patient her ___ interpreter, patient endorses depression but denies suicidality. He does state that he does not want an IV or any treatment. The ED also discussed in detail with the patient's son, ___. The patient's son reports that his father has been refusing care but has not been expressing any depression or suicidal thoughts to him. Psych was consulted, felt that patient does not have capacity due to delirium. In the ED, initial vitals: 98.0 60 187/81 16 100% RA - Exam notable for: Dry MM, Abd soft, non-distended, mild epigastric tenderness, no focal neuro deficits. - Labs notable for: h/h 9.1/27.9, plt 72, creat 5.2, BUN 32, bicarb 21, AG 19, lactate 1.0, UA 182 WBC, lg leuks - Imaging notable for: CT head limited study but no obvious bleeding, CXR no acute cardiopulmonary process, moderate compression of a vertebral body at thoracolumbar junction of indeterminate age. - RUQUS also ordered with read pending - Patient given: Lorazepam 2 mg, 1L nS, acetominphen 1 g, Cefepime 2g, Vancomycin 1 g. The patient was seen by psych who felt that due to delirium the patient lacked capacity and HCP should be invoked. - The patient was also seen by hepatology who recommended obtaining RUQUS and admitting to ___. - Vitals prior to transfer: 97.5 54 169/85 18 99%RA Of note, the patient was admitted in ___ to ___ for MRSA bacteremia thought to be due to seeding from HD graft. TTE and TEE were both negative for vegetations. He was continued on vancomyin dosed by level after HD, with a plan to continue through ___ with goal vancomycin level ___. He followed up with OPAT/ ID clinic. On arrival to the floor, pt somnolent, arousable, unable to participate in questions CT HEAD W/O CONTRAST showed 1. Severely motion limited examination. 2. In the left pons without large or recent infarction. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Redemonstrated right putaminal and adjacent white matter chronic lacune, unchanged since multiple prior exams. There is no evidence of recent infarction or of hemorrhage. The patient was diagnosed with Urinary tract infection, site not specified, Altered mental status, unspecified. At the time of discharge, the patient had Primary: Toxic metabolic encephalopathy Urinary tract infection Secondary: HBV cirrhosis s/p liver transplant ___ ESRD Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old ___ speaking man with ESRD (on HD ___, HBV cirrhosis s/p liver transplant ___ on cyclosporine c/b large varices and recent upper GIB (___), Afib (on ASA), T1DM, CAD and previous subdural hematoma with persistent neurologic deficits (___), recent admission ___ for MRSA bacteremia thought to be seeding from HD graft, who presented with acute encephalopathy and fever, found to have a UTI. #Goals of care: Patient often refuses medications and will try to pull out lines at dialysis. Today he very clearly said no to the transport team when he was going to be brought to dialysis. There was a family meeting (___) and the patient's wife and son expressed that they had considered hospice for him if his mental status is not going to improve beyond his new baseline since the stroke/hemorrhage. The wife and son expressed the afternoon to think about the next best step for the patient. They will not pursue hospice at this time. # Toxic Metabolic Encephalopathy: Patient presented more lethargic and less responsive than his baseline, likely in the setting of UTI. Patient has history of encephalopathy with infections previously. CT head limited given pt agitation but no gross intracranial hemorrhage seen. His mental status improved with treatment of UTI as below. Neurology was consulted to discuss his long term prognosis. Infectious encephalopathy, which appears to be resolving. On head CT there is no evidence of repeat infarct or new hemorrhage, however he does have significant frontal lobe atrophy. As such, Mr. ___ is expected to return to his cognitive baseline, with the understanding that this baseline will likely involve persistent deficits in executive functioning and that he will likely not improve beyond where he has been in the past 12 months. This assessment was provided to Mr. ___ and his son as part of a family meeting held ___. #Sepsis ___ urinary source: UA suggestive of UTI, with cultures growing E coli. Patient intermittently tachycardic to 110s. As above, patient appears to have had similar encephalopathy in the past in the setting of infections, and he has also increased his rate before with infections. Blood pressures remained stable. He was initially treated with IV cefepime (___), then zosyn (___), then transitioned to Bactrim (___-). He was given IV albumin for volume repletion, which improved his tachycardia. He was continued on Bactrim SS BID with a plan for a total 2 week course to end ___. # HBV cirrhosis s/p liver transplant ___: c/b large varices w/ UGI bleed ___. Continued home cyclosporine 75 mg po q12h, home entecavir 0.5 mg PO 3X/WEEK (___), home Pantoprazole 40 mg PO Q24H. #Pancytopenia: Likely secondary to longstanding immunosuppression with cyclosporine and possibly lamictal effect; likely worsened in the setting of acute infection. His CBC was trended. #ESRD: Continued HD ___. Continued Calcium Acetate 667 mg PO TID W/MEALS; sevelamer CARBONATE 800 mg PO TID W/MEALS #T1DM: On home glargine 10U qHS, 3U qAC, and ISS #HLD: Continued atorvastatin #CAD: Patient has a history of CAD with cardiac cath in ___ w/ 40% mid LAD and 40% diagonal stenoses. Circumflex with 40-50% mid stenosis; RCA with mild diffuse disease; 50% PDA stenosis. Continued isosorbide dinitrate, metoprolol, atorvastatin, and aspirin #Papillary thyroid cancer s/p thyroidectomy: Continued levothyroxine 100 mcg daily. #HTN: Continued home amlodipine, isosorbide. Held lisinopril and clonidine. #Afib: CHADS-VASC 5 but not on anticoagulation given a history of subdural hematoma and GI bleed. Continued metoprolol tartrate 50 mg Q6H. #h/o seizure disorder: continued home LevETIRAcetam 250 mg PO BID #h/o depression: continued home Sertraline 25 mg PO DAILY #Vitamin D deficiency: continued home Vitamin D 1200 UNIT PO DAILY #Glaucoma: continued home Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS Transitional issues =================== - New medications: Bactrim (___) - Recommend urology follow up for recurrent UTIs - Follow up glucose control and adjust insulin as needed - Lisinopril discontinued as blood pressures well controlled without it (and sometimes on lower end in systolics 100s) - Recommend nutrition follow up for discussion of feeding tube if patient continues to refuse medications and food, while family choosing to continue to pursue aggressive care - Cyclosporine level goal 50-100 - Draw next cyclosporine on ___ and fax results to ___: ___ - Continue goals of care discussion with family - HCP ___ (son) ___ - Code status: DNR/DNI</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old young woman with a past medical history of cerebral palsy who presents with increased mucous production for the past 2 weeks. She is non-verbal and is accompanied by her father who serves as the historian. She does have oral secretions at baseline, managed successfully as an outpatient with ranitidine. However, over the past two weeks she has had an increase sputum production with a mild cough and associated chest tightness. He has tried over the count expectorants with intermittent improvement throughout the past two weeks. However, the mucous production was more pronounced today, which prompted him to bring his daughter to the ___. There is no associated wheezing or shortness of breath. There is no nausea or vomiting. There are no sick contacts. He notes that she has maintained her appetite and there has been no decreased PO intake at home. No change in urination/color/appearance. There is no history of DVT/PE in the patient or in the family. The patient is wheelchair bound and thus relatively immobile. Initial vitals in the ___ 100.2 130 136/89 25 98% RA Radiology showed No visualized acute cardiopulmonary process. Radiology showed Limited examination. No evidence of acute cardiopulmonary process. Radiology showed No evidence of lower extremity deep venous thrombosis in either the right or the left lower extremity. CTA chest showed 1. No evidence of pulmonary embolism. 2. Endoluminal filling defects seen within the right lower lobe bronchi, particularly within the posterior and lateral basilar bronchopulmonary segments. NOTIFICATION: The findings regarding endobronchial plugging were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 1:55 ___, 5 minutes after discovery of the findings. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had Increased oral secretions Endobronchial plugging Tachycardia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old young woman with a past medical history of cerebral palsy who presents with increased mucous production x2 weeks, found to be tachycardic in the ___ with elevated lactate and admitted to medicine for further management. # Increased mucous production/increased oral secretions: Ms. ___ presented with increased oral secretions appearing uncomfortable and moaning on initial exam, with fever to 100.2. Given her symptoms and low grade fever, she was treated empirically for community acquired pneumonia with Ceftriaxone and Azithromycin. The other etiology of presentation included the possibility that she had a sore throat and was reluctant to swallow her secretions, which eventually built up and caused her distress. She underwent CTA to further evaluate her tachycardia as below, with the incidental findings of endobronchial plugging of the right lower lobe. She underwent suctioning overnight and was back to her baseline on hospital day #2, according to her father who is her primary caregiver. She is discharged home to complete a course of antibiotics for CAP and with ___ services for deep suctioning three times weekly. Respiratory viral culture is pending on discharge and the patient was instructed to wear a mask until contacted with the final results. # Tachycardia: Ms. ___ presented with tachycardia to the 130s, confirmed on EKG to be sinus tachycardia, as well as elevated lactate to 3.9. She received a total of 5L IVF with improvement of heart rate to the low 100s. Initial EKG was concerning for S1, Q3, T3 pattern. Given that her tachycardia did not completely resolve even after 5L IVF, she was evaluated for PE. LENIs were negative for DVT and CTA scan was negative for PE (though notable for incidental findings as described above). The etiology of her tachycardia was thought in part secondary to hypovolemia as well as physiologic response to endobronchial plugging. Prior to discharge she demonstrated the ability to tolerate PO intake and she was discharged with ___ services for deep suctioning as above. # Cerebral Palsy: Patient undergoing ___ as outpatient. Disposable liners provided in house for incontinence. # Constipation: Continued on home Miralax # Secondary amenorrhea: Patient on medroxyprogesterone as needed for no menstruation every ___ months. She is currently not taking this medication.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ female with coronary artery disease, prior STEMI with stent placement and pacemaker placement for cardiac arrest, aortic stenosis with a mean gradient of 17 mmHg (low gradient) who presents after likely mechanical fall at her living facility. The details surrounding the fall are unclear as the patient has some dementia at baseline. In discussing with her son it is likely that she had a mechanical fall. Workup in the ED has been negative. She is currently endorsing pain in the hip. She is denying pain elsewhere. Radiology showed Comminuted, displaced left intertrochanteric fracture, with varus angulation of the femoral head. No fracture of the more distal left femur. Radiology showed No acute cardiopulmonary process. HIP UNILAT MIN 2 VIEWS LEFT showed Spot images are submitted for documentation of an invasive procedure performed under imaging guidance with no radiologist in attendance. For details of the procedure, please refer to the operative report. The patient was diagnosed with Displaced intertrochanteric fracture of left femur, init, Fall same lev from slip/trip w/o strike against object, init. The patient was treated with ___: Left TFN. At the time of discharge, the patient had Left intertrochanteric femur fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left intertrochanteric femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left TFN, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated left lower extremity , and will be discharged on Lovenox for DVT prophylaxis and will also continue her dual antiplatelet therapy. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: The patient is a ___ PMHx L frontal lobe infarct (___), L temporal-parietal grade 2 meningioma s/p resection ___, CAD s/p MI, HFpEF, stage III CKD, PAD, HTN, T2DM on insulin, and atrial fibrillation not on AC (unclear reason) who presents with dysarthria and left facial droop. ED CODE STROKE ONLY CT showed 1. A 1.9 cm extra-axial hyperdense lesion with suggestion of calcifications in the right parietal convexity without hyperostosis of the overlying bone. This may represent a meningioma but cannot definitively exclude extra-axial hemorrhage. 2. Expansion of the sphenoid triangle with mixed sclerotic and lytic lesions by an abnormal soft tissue density primarily located in the anterior portion of the middle cranial fossa extending to the left sphenoid sinus with an intra-orbital component leading to mass effect on the left lateral rectus muscle, retro-orbital fat, and proptosis. These findings may be related to an intraosseous meningioma with soft tissue extension and postoperative changes from prior left pterional craniotomy. RECOMMENDATION(S): For both of the above findings, correlate with prior imaging or alternatively follow-up with MR. CT C-SPINE W/O CONTRAST showed 1. No fracture or malalignment. 2. Degenerative changes with posterior disc bulge at C3-C4 and C4-C5 causing at least moderate spinal canal narrowing and presumed spinal cord remodeling. MRI AND MRA BRAIN AND MRA NECK PT11 MR ___ showed 1. Status post left pterional craniotomy for meningioma, with area of enhancement in the left middle cranial fossa as described above, suspicious for recurrence. 2. Redemonstration of calcified right parietal meningioma. 3. Acute infarction within the right frontal temporal lobes and in the left precentral gyrus. 4. Chronic infarction within the right cerebellar hemisphere. No intracranial hemorrhage. 5. Diffuse parenchymal volume loss with nonspecific white matter signal abnormality, likely a sequela of chronic small vessel ischemic disease. 6. Unremarkable MRA head. 7. Difficult to assess right vertebral artery with areas of non enhancement which may be related to atherosclerotic disease. Otherwise, unremarkable MRA neck. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:40 am, 2 minutes after discovery of the findings. The patient was diagnosed with Cerebral infarction, unspecified, Slurred speech. At the time of discharge, the patient had right MCA stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ year old woman with a PMHx of L frontal lobe infarct (___), L temporal-parietal grade 2 meningioma s/p resection ___, CAD s/p MI, HFpEF, stage III CKD, HTN, T2DM on insulin, and atrial fibrillation not on AC (unclear reason) who is admitted to the Neurology stroke service with L facial weakness and dysarthria secondary to an acute ischemic/hemorrhagic stroke in the R MCA. Exam notable for dysarthria, left NLFF but good activation and left pronator drift with subtle left proximal weakness that has improved. MRI with acute infarction within the right temporoparietal lobe and a small infarction in the left precentral gyrus, as well as chronic infarction within the right cerebellar hemisphere and diffuse parenchymal volume loss with nonspecific white matter signal abnormality, likely a sequela of chronic small vessel ischemic disease. Her stroke was most likely secondary to a cardioembolic event, given her history of atrial fibrillation not on AC and pattern of acute MRI changes. Her calculated CHADS-VASc Score is 9, indicating a ___ risk of stroke per year. The benefits of anticoagulation for prevention of further strokes is greater than the risk of bleeding in this situation. Therefore, we have added Apixaban 2.5mg BID to her current medication regimen. She technically qualifies for 5mg BID dosing, given that her Cr at discharge was below 1.5 and her body weight is greater than 60 kg. However, because she is ___ and her Cr was 1.9 on admission, coupled with her history of neurosurgery (meningioma s/p resection), we will start her on 2.5mg BID for ___ weeks, with a plan to increase her dose to 5mg BID at her stroke followup appointment, if tolerated. Her deficits improved greatly prior to discharge and the only notbale weakness was in the L IO muscles with subtle L pronator drift, as well as mild dysarthria. She also has chronic visual deficits. She will continue rehab at home with home ___, with speech/swallow follow up.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with a history of atrial fibrillation on aspirin/amiodarone therapy, hypertension, hyperlipidemia, left sided subclavian steal and a lung nodule who presents to the ED with a brief episode of right arm numbness and impaired speech. On the morning of admission, she had just finished eating breakfast when she went into her room and started folding clothes. She noticed that her right hand felt numb. It was not clumsy at the time and she noted that she was able to fold clothes without difficulty. Shortly thereafter, she noted that the tongue felt like it was pushing upwards on the right side of her mouth. She went to speak to her daughter about this and noted that she simply couldn't get any words out. When finally she could use some words to express herself, her speech was slow, stuttering and slurred. Apparently she was able to write her thoughts down. She had ___ difficulty comprehending commands around her. The numbness went away within 5 minutes but the speech difficulties persisted for about 1 hour. Her daughter now reports that the right side of her face was droopy, but is much improved now. The daughter also confirmed that her mother's speech and fluency was much better than previous. Review of systems is positive for difficulties with left sided thigh pain and some recent issues with neck pain. She has not had nausea, emesis, chest pain, congestion, cough, abdominal pain, dysuria, hematuria. She denied double vision or headache during these symptoms. Radiology showed No acute intracranial process. Radiology showed Age-related involutional and chronic microangiopathic changes without evidence of acute infarct, hemorrhage, or mass effect. Entire left vertebral artery is markedly diminished in caliber with severe stenosis just beyond the origin likely related to atheromatous disease, as well as diminutive right A1 and P1 segments. The patient was diagnosed with TRANS CEREB ISCHEMIA NOS. At the time of discharge, the patient had TIA. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman w AFib on amio and ASA, history of left subclavian steal syndrome, HTN/HLD who developed acute onset of right hand numbness followed by diminished speech output and dysarthria initially concerning for TIA/stroke. On admission, her symptoms had largely resolved and neurological exam was significant only for mildly slurred speech. Code Stroke was called with ___ for dysarthria. CT/CTA and MRI have showed ___ acute lesion or gross vascular compromise, although severe stenosis of the left vertebral artery due to atherosclerosis was seen. Labs do not identify gross metabolic disturbances. TIA with possible thromboembolic etiology from transient Afib vs small vessel disease. ___ evidence to support vertebrobasilar ischemia despite her history of subclavian steal. During this admission she had a brief run of transient questionable Afib with HR 130s that resolved in less than 30 seconds. We had lengthly discussions about her stroke risk due to paroxysmal Afib going forward, but she continues to defer anticoagulation due to concerns about bleeding. She would like to discuss possibly starting Pradaxa after discussion with her PCP. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w h/o well controlled asthma presenting with 4 day h/o abdominal pain. Patient notes that she developed sharp RUQ/RLQ pain 4 days ago toward the end of her menses. The pain was constant and gradually worsened and spread across her abdomen. Over the same period, she has experienced nausea and constipation with last bowel movement ___ days ago. She reports chills but no fever, denies dysuria, frequency urgency. No recent travel or sick contacts. No h/o abdominal surgery. Radiology showed Unremarkable bowel gas pattern. Radiology showed 1. Slight bowel wall thickening and enhancement in the proximal jejunum followed by a segment of mildly dilated bowel, which is fecalized. This is followed by a non-abrupt transition zone and a region of collapsed small bowel. These findings could be secondary to an inflammatory process such as gastroenteritis or could represent intermittent, partial, or resolving small bowel obstruction, although dilatation is not striking. Correlation with physical findings and clinical presentation are recommended. There are no findings to suggest internal hernia or mesenteric involvement. 2. Multifocal chronic scar formation in the bilateral kidneys. Radiology showed No evidence of obstruction. Decreased interval amount of fecal load compared to the study from ___. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had Primary diagnosis: Constipation Depressed mood Secondary diagnosis: Asthma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o well controlled asthma who presented with 4 day h/o abdominal pain in the setting of constipation. # Constipation: Presented with ___ days of constipation, no prior h/o severe constipation. Reported that she eats plenty of fruits and vegetables, drinks ___ glasses of water daily and had had occasional constipation relieved with OTC laxatives, no chronic laxative use. No recent changes in medications or diet, no narcotic pain meds at home, although received several doses of morphine and hydromorphone in ED. Based on imaging and ACS consult, no concern for active SBP, although inflammation on CT abd/pelvis may represent resolving obstruction. Was started on bowel regimen which was gradually intensified. Pt was able to have several bowel movements on day of discharge. Discharged patient home with bowel regimen and plan to follow up with nutrition for outpatient nutrition education to prevent recurrent constipation. . # Abdominal Pain: Gradual onset in the setting of severe constipation. Initial KUB suggestive of constipation, CT abd pelvis with nonspecific inflammation of proximal jejunem. Abd exam remained benign, pain improved after patient was able to move bowels, repeat KUB showed decreased fecal load. Repeat lipase, LFTs normal. . # Anxiety/Depressed mood: Likely contributor to abdominal pain/constipation. Patient was noted to have significant anxiety/depressed mood related to stress from difficult family dynamic. Reported tension between herself and her husband related to fertility issues. Has very strained relationship with her mother, who she reports forced her to undergo a medical procedure in the ___ as a teenager which she now believes was a tubal ligation. Her mother reportedly is very intrusive in her family life and she and her husband decided during the admission to move to another ___ to mitigate the situation. She was initially very tearful, but affect greatly improved after discussion with SW. Medical team recommended continued outpatient SW follow up and consideration of initiating SSRI if symptoms persist. Discharged home with short course of low dose lorazepam. . # Asthma: Well controlled on rescue inhaler only. Never hospitalized or intubated for asthma. Continued prn albuterol MDI.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is an ___ y/o F with severe Alzheimer's, HTN, osteoarthritis, osteoporosis with one month long history of inability to bear weight on the LLE who presented on ___ after imaging showed femoral neck fracture and is now s/p L hemiarthoplasty, found to have urinary retention and UTI with post op course complicated by anemia. Radiology showed Recent impacted left femoral neck fracture which could be from trauma 1 month prior. Vertically-oriented lucency within the proximal right femur may be due to overlying tissues however if patient has symptoms on the right side, consider additional imaging to exclude fracture. HIP 1 VIEW showed In comparison with the study of ___, there is now a left hemiarthroplasty in place in the left hip. No evidence of hardware failure complication. The patient was diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL, HYPERTENSION NOS, ALZHEIMER'S DISEASE. The patient was treated with Left hip hemiartrhoplasty. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left hip hemiarthroplasty, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to her baseline diet and oral medications by POD#2. The patient was given perioperative antibiotics and anticoagulation per routine. She did require blood transfusion for postop Hct of 22.5. Her Hct stabalized at 33.3 2 days post-transfusion. The patient was also found to have UTI with pan-resistant E. coli and was started on IV meropenem per medicine recommendations, which she will continue upon discharge. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient's family regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old woman with DLBCL finishing C6 DA-EPOCH-R who is admitted from the ED with febrile neutropenia. Patient speaks ___, and history is taken with the aid of her husband, at bedside. Chest: Frontal and lateral views showed Subtle opacity in the retrocardiac region could be seen in the setting of an infectious process. NOTIFICATION: Updated findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:45 pm, 10 minutes after discovery of the findings. The patient was diagnosed with Neutropenia, unspecified, Fever presenting with conditions classified elsewhere. At the time of discharge, the patient had PRIMARY DIAGNOSIS: ================== #Febrile Neutropenia #DLBCL SECONDARY DIAGNOSIS: ===================== #Chronic HBV infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT AND PLAN: Ms. ___ is a ___ y/o female with a hx of high-grade DLBCL (CD5+, BCL6 gene arrangement) s/p cycle 6 da-EPOCH-R (c6d1 ___ who presented with febrile neutropenia. Overall, she is doing well clinically and HD stable. #Febrile neutropenia: Presented with ___ SIRS (fever/HR) and elevated lactate concerning for severe sepsis. Additionally, ANC was 90 on admission. Initially, she was started on vancomycin, cefepime, and oseltamivir. However, no infectious source was found; therefore, we de-escalated antibiotics. -Cefepime ___ Vancomcyin [___] -Discontinued Tamiflu with viral swab negative -BCx/urine culture--NTD #Diffuse large B-cell lymphoma: Diagnosed with high grade DLBCL in ___. Cytogenetics notable for CD5+ and BCL6 rearrangement. Initial involvement of C3 paraspinal mass, spleen, putamen, and diffuse lymph nodes (axillary, retroperitoneal, pelvic, mesenteric). S/p 6 cycles of da-EPOCH-R with prophylactic intrathecal MTX. Plan to re-image after cycle 6. Currently, she is day 18 of cycle 6 of EPOCH. Her counts have recovered. -VZV PPx: Continue acyclovir 400 mg q8h -PCP ___: Discontinued atovaquone at discharge per Dr. ___ -___ up scheduled for ___ with Dr. ___ scheduled for ___ #Pancytopenia: Resolved. Likely due to most recent cycle of EPOCH-R. Filgrastim discontinued ___ with counts recovery. She needed PRBCs transfusion on ___ but no other transfusions needed during her hospital course. -Transfuse for Hgb <7 or plt <10 #Chronic HBV Infection: Receiving monthly viral load monitoring. Last level on ___ was detected but less than 1.3. Continue home regimen of entecavir </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with bicuspid aortic valve stenosis and mitral regurgitation post-tandem surgical mechanical AVR/MVR, complete heart block post-CRTP, valvular cardiomyopathy and recent hospitalization for ICD upgrade after sustained monomorphic VT who presents several hours after last discharge with palpitations. CHEST (PA AND LAT) showed 1. No focal consolidation or pulmonary edema. 2. Stable moderate cardiomegaly with mild pulmonary vascular congestion, however no overt interstitial edema. CHEST PORT. LINE PLACEMENT showed Mild pulmonary edema. The tip of the Swan-Ganz catheter projects over the left lower lobe pulmonary artery. CHEST (PORTABLE AP) showed The tip of the Swan-Ganz catheter has been minimally retracted however still projects over the left pulmonary artery. Mild pulmonary edema. Otherwise no significant interval change. CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK showed 1. No definite evidence for acute large territorial infarct, intracranial hemorrhage or intracranial mass effect noncontrast CT head. 2. Asymmetric hypodensity of the right frontal white matter likely represents sequela of chronic microangiopathy however subtle acute infarct could potentially be obscured. 3. Suboptimal CTA examination secondary to contrast bolus timing. Within this confines: 9 mm left supraclinoid ICA aneurysm with 4 mm neck as well as a 5 mm right supraclinoid ICA aneurysm. The remainder of the intracranial circulation demonstrates no evidence of high-grade stenosis or occlusion. 4. Unremarkable CTA of the neck within confines of technically suboptimal exam. 5. CT perfusion does not demonstrate CBF less than 30%. 6. Additional findings as described above. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Dense opacification of the left lower lobe is new, more likely collapse than pneumonia. Moderate pulmonary edema has redistributed, now most pronounced in the dependent right lung. Small pleural effusions are unchanged. Moderate enlargement of cardiac silhouette may have increased, function of lower lung volumes and relative increase in central venous return with the termination of positive pressure ventilation. Sternal wires are intact and aligned. Transvenous right atrial ventricular pacer defibrillator leads and epicardial leads unchanged in their respective positions. Right jugular sheath ends in the mid SVC following removal of the Swan-Ganz catheter. CHEST (PA AND LAT) showed Compared to chest radiographs ___ through ___. Previous pulmonary edema has largely cleared. Right lower lobe shows persistent atelectasis adjacent to moderate right pleural effusion. Severe cardiomegaly unchanged. No pneumothorax. Transvenous right atrial ventricular pacer defibrillator leads and 2 epicardial leads are continuous from the left pectoral generator. UNILAT LOWER EXT VEINS LEFT showed Moderate to severe soft tissue swelling over the left calf. No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with Palpitations. The patient was treated with ___ Redo Mitral valve replacement with a 29 mm ___ mechanical valve. (Prior mechanical aortic valve). At the time of discharge, the patient had Primary: Redosternotomy s/p Mechanical Mitral Valve Replacement RV lead extractions with upgrade to a CRT-D device on ___ postop ischemic stroke with Left weakness Secondary: aortic stenosis s/p prior Mechanical Aortic Valve Replacement and Mitral valve repair with 30mm ___ II ring and LV epicardial lead placement ___ Complete Heart Block-s/p Permanent PaceMaker ___ hypertension hyperlipidemia BPH Shingles Valvular cardiomyopathy mitral regurgitation Atrial fibrillation H. pylori gastritis post-quadruple therapy (___). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ MEDICAL COURSE: ___ male with bicuspid aortic valve stenosis and mitral regurgitation post-tandem surgical mechanical AVR/MVR, complete heart block post-CRTP, valvular cardiomyopathy and recent hospitalization for ICD upgrade after sustained monomorphic VT who presented after last discharge with ongoing palpitations, with plan for MV paravalvular leak repair. on ___, he went to the OR for his MV paravalvular leak repair. #Monomorphic VT, sustained, s/p ICD upgrade #Palpitations Mr. ___ presented with continued palpitations after CRTD placement and lead extraction on ___. No events with pacer interrogation. Patient noted to have short runs of non-sustained VTs on telemetry accompanied by palpitations. Concern for pocket hematoma noted on ___ in the setting of heparin infusion. #HFrEF ___ LVEF 37%) #Valvular cardiomyopathy post-tandem mechanical AVR/mitral repair. # Severe MR ___ on ___ showing severe MR with dehiscence of the mitral annular ring. Currently appears euvolemic so he was kept on his home diuretic dosing. #Hemolytic anemia iso mechanical valve Stable. #Hepatitis B Patient with positive HepB core Ab. HBV viral load was nondetectable during last admission. RUQUS with normal hepatic parenchyma. #Pulmonary Nodules Incidentally found on ___nd 3 month follow up scan recommended by radiology. #Small Left hematoma s/p ICD upgrade </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old lady with history of CAD s/p CABG *3 ((LIMA-LAD, SVG to OM1, SVG to PDA), cath in ___ w/occluded SVGs x 2, patent LIMA), Type I Diabetes with ESRD s/p renal transplant in ___ on chronic immunosuppressive agents and severe gastroparesis presenting from OSH with elevated Cr and anemia. She had presented to ___ yesterday with decreased urine output x1 week with no urine output for 24 hours and weakness, noted to not be in retention, but with Cr elevated to 3.2 from baseline of 2.3 and HCT of 17 from baseline of 28. She was transfused 2U PRBC but not given IV furosemide according to her husband. ___ was WNL prior to the transfusion. She was transferred to BI for renal evaluation. On arrival to the ED, initial VS were notable for brady to 40-60. Per notes, "seemed intoxicated." Creatinine 2.8. HCT 23.2. Benign exam. US notable for no hydro, high resistive index. Renal fellow felt findings non-specific. Placed foley, not retaining, 100cc/out, UA pending. Trop 0.04. EKG: biphase T waves laterally, sinus brady. Got 1 more unit pRBCs. Admitted to hepatorenal for further management. This morning, she was very lethargic but not confused. She has been this way for one week. She also notes weakness in her arms and jaw, along with pain. This started one week ago. She has no fam hx of neurolgical disorders. Feels that her eyes close by themselves at the end of the evening. Feels that her symptoms worsen in the evening. No dysuria. No cough, no shortness of breath, no chest pain. History also obtained from husband, meds as well. He notes no changes in diuretics except to decrease metolazone from BID to QD one month ago. *** Records also obtained from ___: recent labs and ED evaluation note *** Radiology showed AP chest compared to ___: In addition to chronic pulmonary vascular congestion, there is progressive consolidation at the base of the right lung, consistent with pneumonia. Moderate cardiomegaly is longstanding. Tiny right pleural effusion may be present. No pneumothorax. The patient was diagnosed with RENAL & URETERAL DIS NOS, ANEMIA NOS, KIDNEY TRANSPLANT STATUS. At the time of discharge, the patient had Primary: CHF exacerbation Acute kidney injury Chronic kidney dysfunction Type 1 Diabetes Anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF HOSPITAL COURSE =============== ___ year old female with history of CAD s/p CABG, Type I Diabetes with ESRD s/p renal transplant in ___ on chronic immunosuppressive agents who was transferred to ___ with elevated Cr, evidence of pulmonary vascular congestion, and anemia (she received 4 units of pRBCs). Her creatinine was actually at her baseline. She was diuresed and underwent work-up which revealed new worsened biventricular systolic dysfunction. She was also found to have community acquired pneumonia, and underwent a 7 day course of levofloxacin. Her course was complicated by labile blood sugars. She was started on EPO for anemia related to kidney disease, and was discharged with follow-up with a new nephrologist, as well as ___ transplant nephrology. ACTIVE ISSUES ========= # CHF exacerbation with volume overload: She was noted to have pulmonary vascular congestion on admission. She is s/p kidney transplant in ___ with new worsened systolic function and tricuspid regurgitation. Volume overload was in the context of recent down-titration of diuretic medications in the past month. Creatinine normalized to her baseline (mid 2.0's) during admission. She was treated with intravenous diuresis and restarted on her home regimen of metolazone and torsemide at discharge. - She may need pulmonary investigation in the future due to new biventricular systolic dysfunction AND new pulmonary artery hypertension (esp given that LV dysfunction seems more mild than RV dysfunction). # Pneumonia: She was noted to have radiographic findings of pneumonia and was started on levofloxacin for treatment of community acquired pneumonia. This regimen was not ideal given her prolonged QTc, but she has a penicillin allergy. She underwent an 8 day course (levofloxacin frequency was decreased in the context of chronic kidney disease). # Anemia: She was transferred from an OSH with significant anemia, s/p 2 units of pRBCs at OSH and 2 units at ___. She underwent work-up which was more consistent with anemia of chronic [kidney] disease. She was guaiac negative in the ED and had no evidence of hemolysis (of note, haptoglobin was normal prior to transfusion at ___ - see scanned records for further details). She was started on EPO during her admission; this will be continued by her new nephrologist. She was hemodynamically stable during admission. # Acute on chronic kidney disease s/p renal transplant: She underwent kidney transplant in ___. She was continued on her immunosuppressives and tacrolimus level was sent daily. She should follow up with Dr. ___ at ___, and will follow with a new nephrologist closer to her home. #) Diabetes (type 1): This appears to be brittle diabetes; she had episodes of early morning hypoglycemia. ___ was consulted and her insulin sliding scale and once daily lantus were adjusted accordingly. This could also have been exacerbated by changing renal dysfunction. By discharge, hypoglycemia resolved and blood sugars were better controlled. # Prolonged QTc: She had elevated QTc, possibly due to taking standing prochlorperazine TID at home in conjunction with other QTc prolonging medications, such as tacrolimus. Her magnesium was consistently repleted. She was started on levofloxacin during admission for pneumonia (due to allergies) and QTc was carefully monitored. It was 485 on the day of discharge with fully repleted magnesium. CHRONIC ISSUES ========== #) CAD/PVD: She was continued on aspirin, atorvastatin, and clopidogrel. # Tobacco cessation: She declined nicotine patches saying she lacked cravings. She was counselled on the importance of quitting tobacco, especially due to her chronic medical problems. She is not yet ready to quit but will consider. #) Depression: Continued cymbalta. TRANSITIONAL ISSUES ============== - Code status: DNR/DNI, confirmed with patient on admission. - Emergency contact: husband, ___, ___, ___. - Studies pending at discharge: All micro that was pending is now finalized and added to discharge summary. - She may need pulmonary investigation in the future due to new biventricular systolic dysfunction and new pulmonary artery hypertension, especially given that LV dysfunction seems more mild than RV dysfunction. - Use care with QTc prolonging medications (she and her husband were counselled on only taking compazine as a PRN). - Needs EPO prescription and monitoring of her HCT. - She has follow-up with a hematologist for bone marrow biopsy (this was rescheduled as she missed prior appointment during admission). - A copy of this discharge summary was faxed to Dr. ___ at ___ nephrologist) at ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with DM type II and HTN presenting with hypotension, anemia, LBBB in setting of elevated troponin, and right upper lobe opacity. Pt reports that his biggest underlying complaint for several months has been right shoulder pain for which he has been seeing his PCP. He has undergone steroid injections and physical therapy with minimal relief. He has felt increasing short of breath with physical therapy sessions. He also noted frequent diarrhea, general malaise, and poor appetite for at least 3 weeks. He believes he has had a twenty lb weight loss over the course of several months. He has also had subjective fevers/chills, night sweats, and urinary frequency. He went to see a gastroenterologist on ___ for his diarrhea. There he was noted to be hyoptensive with BPs in systolic ___ and Hct was 21. He was referred to ___ ___. At the ED, guaiac was reportedly negative. He believes he had a colonoscopy in ___ that showed one polyp and has not noticed black or bloody stools. EKG revealed LBBB without any prior for comparison. Calcium was elevated to 11.7 (albumin 2.7). WBC 19.2. Hct 21. Blood sugars ___. Troponin I was elevated to 1.9. Cardiology was consulted who felt that this was likely demand ischemia from anemia. Pt denies chest pain. He also had urinary retention; foley was placed with 1L urine output. He was given aspirin and transfused 1 unit PRBC prior to transfer to ___ ED for further evaluation. Radiology showed Right upper lobe opacification with abnormal inferior margin and volume loss without mediastinal shift, concerning for space occupying process in the right upper lobe which may involve the mediastinum. Differential diagnosis includes malignancy. CT is recommended for further evaluation. These findings and recommendations were discussed with Dr. ___ by Dr. ___ by telephone at 1:05 a.m. on ___ at the time of discovery of these findings. Radiology showed 1. Large right upper lobe mass extending from the right hilum to the right chest wall with destructive involvement of the second and third right ribs. The right upper lobe bronchus is completely occluded. 2. 6 mm subpleural nodule in the right lower lobe may represent a satellite lesion. Attention on follow up. 3. Indeterminate left adrenal nodule, incompletely characterized on this study. This may represent a metastatic lesion. If no prior imaging is available characterizing this lesion, this could be further evaluated by adrenal protocol CT or MRI if clinically indicated. 4. No acute process in the abdomen or pelvis to explain patient's chronic diarrhea. 5. 1.8-cm right renal superior pole hypodensity with intermediate density (22HU) could be further evaluated by renal ultrasound. 6. Mild emphysema. Mild pulmonary artery enlargement suggests underlying pulmonary arterial hypertension. 7. Prostatic enlargement with circumferential bladder wall thickening suggests outflow obstruction. 8. No definite evidence of spinal metastases as clinically queried, although MRI is more sensitive. 9. The imaged portion of the right shoulder is unremarkable. Findings discussed with Dr. ___ fellow) by phone at 5:20pm ___. Radiology showed 1. No focal lytic bone lesions. 2. Large right upper lobe lung mass, better assess on the prior CT scan. 3. Degenerative changes. Radiology showed Technically successful ultrasound-guided right upper lobe lung lesion biopsy with two 18-gauge core biopsy samples obtained. No immediate complications. Samples sent to Pathology for further analysis. The patient was diagnosed with SHORTNESS OF BREATH, ANEMIA NOS, MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, PNEUMONIA,ORGANISM UNSPECIFIED, DIABETES UNCOMPL ADULT. The patient was treated with Ultrasound guided lung biopsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>RUL lung mass: Initial finding of space occupying process on CXR prompted CT evaluation, which revealed a substantial RUL mass from hilum to chest wall, destroying the second and third ribs. This large mass was biopsied through US guidance, and the results were still pending at the time of discharge. The medical team discussed with the patient that malignancy was high on the list of differential diagnosis. Urinary retention: At ___, 1L urine output was obtained after foley was inserted. At home, patient notes that he will urinate frequently and excrete very small volumes. At ___, Abd CT revealed symmetric bladder wall thickening and enlarged prostate, suggestive of outflow tract obstruction. He received a foley for two days, and then failed two trials to void with 700 mL and 800 mL of residual in the bladder. The patient reported he did not feel the urge to urinate with these volumes. He was started on tamulosin 0.4 mg QHS for presumptive BPH. Hypercalcemia: At ___, patient's corrected calcium was 12.7. At ___, PTH of 6 which is markedly low. Likely hypercalcemia of malignancy given imaging findings. Ordered PTHrP to confirm diagnosis, which was still pending at discharge. Received aggressive IV hydration for a total of about ___ liters since admission, and his calcium trended dowards to correct calcium of 11.5. He also received 1 dose of pamidronate and 1 dose of lasix to further diminish his hypercalcemia. We discontinued his Vitamin D therapy given his hypercalcemia. Consideration should be given to starting a bisphosphonate routinely if confirmed hypercalcemia of malignacy. On discharge, his calcium was WNL at 10.2. Phosphorus was low at 2.4 on day of discharge and he required several packets of neutraphos for repletion. His electrolytes should be checked on a daily basis and repleted as needed while at rehab. Hypoglycemia/DM2: Pt reports low blood sugars at home and had sugars in ___ at ___. Hypoglycemia likely from poor po intake in setting of continued oral hypoglycemics (glimeprimide, metformin). During hospitalization, held hypoglycemic agents and monitor QID fingersticks. FSBG came up nicely to 120s-150s after IVF. Given his lack of appetite, we discontinued his oral anti-hyperglycemics in order to prevent further hypoglycemic episodes. Anemia, inflammation: Pt with Hct of 21 at ___ and received 1 unit PRBC prior to transfer from ___. Etiology of anemia initially unclear butt likely anemia of chronic disease given RUL lung mass. Guaiac negative with good rectal tone. Additionally had colonoscopy in ___ which showed 1 rectal polyp but was otherwise unremarkable. He received 1U PRBC in the MICU prior to transfer to the floor. Hct was 29 on the floor and stable throughout the remainder of the hospitalization. Iron studies showed high ferritin and low TIBC, suggesting anemia of chronic disease as the primary etiology. chronic systolic CHF: TTE showed significant inferior wall motion abnormalities with diminished EF (35-40%). His enalapril was held throughout his hospitalization secondary to hypotension in the setting of hypovolemia; similarly, initiation of diuretic therapy was held. Leukocytosis: On admission, his WBC was elevated to ___. Pt does not have localizing symptoms to suggest infection, urine culture and blood cultures with no growth, Chest CT with complete oblieration of RUL suggesting no physical space for infection. No fevers documented at ___ or here and continued to be afebrile in the throughout the hospitalization. Possibly stress response vs consequence of malignancy. Hypotension (resolved): Pt with reported low blood pressures in systolic ___ at PCP's office. At our ED and in the MICU, BPs were 100s-110s. After IVF on the floor, BPs remained in 110s and he was not orthostatic. Hypotension was likely secondary to volume depletion (diarrhea, frequent urination secondary to hypercalcemia, poor po intake). Infectious cause was considered possible given elevated WBC of ___, however patient was afebrile and reported no localizing symptoms. He received 750mg IV levofloxacin for right upper lobe opacity concerning for PNA, but this was discontinued as malignancy appeared more likely than pneumonia. Additionally also had TTE to look for pericardial effusion which was negative. NSTEMI (resolved)/CAD: Had elevated trop I at ___ and in house with elevated trop T of 0.85. EKG showed LBBB with nonspecific ischemic changes (STE in V1-3, STD V5-6). There were no prior EKGs for comparison, but did not meet Sgarbossa criteria for diagnosing an acute MI in the setting of a LBBB. Cardiology saw the pt and felt he likely has stable CAD and diastolic dysfunction and presented with demand-related ischemia in setting of anemia and hypovolemia. Bedside TTE suggested inferoseptal and inferior wall hypokinesis, with normal RV, EF 50%, moderate pericardial effusion without tamponade. His troponins peaked at 0.87 and trended downwards thereafter. A formal TTE revealed diminished EF (35-40%), inferior wall motion abnormalities, and mitral regurgitation. Once his hypotension resolved, he was started on a low dose beta blocker. Diarrhea (resolved): Pt reported history of IBS and frequent diarrhea at home. Initially he had diarrhea, and in the context of marked leukocytosis, C. diff toxin assay was sent and he was empirically started on antibiotics. C. diff assay was negative and the diarrhea resolved spontaneously. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M w/ hx of T2DM, ESRD s/p cadaveric kidney txp in ___ c/b ACR ___, HTN, hypothyroidism p/w 2 weeks of dull, gnawing LUQ abdominal pain and nausea. He notes that he has lost all appetite and has had very little except crackers and water with his pills over the last two weeks. He has never had anything like this before. He denies hx of gallstones, EtOH use, new medications, OTC supplements. Nothing has made it worse or better but pain has been persistent over the two weeks. He denies vomiting, constipation, black or bloody stools, diarrhea. He denies confusion or change in urination. He initially presented to ___ and was found to have Na 125 creatine 1.5 BUN 16 AST 156 ALT 259, alk phos 93. ___ tried to transfer for ___ but hospital is full so transfered to ___ for futher care. In the ED initial vitals were:99.8 72 146/78 18 98% - Labs were significant for UA with protein/glucose/ketones, K 5.2->4.8, Na 128, Bicarb 19, Cl 96, Cr 1.3, BUN 18, Glu 317, Mg 1.5, ALT 269, AST 155, Lipase 514, AP 100, Tbili 0.4, Alb 4.0, H/H 12.3/36.8, Plt 138 - Patient was given 2L NS, IV ondansetron 4mg, MMF 500mg, tacrolimus 1mg, insulin Vitals prior to transfer were: 99.3 80 168/65 16 99% RA On the floor, patient notes that pain is unchanged over the last several weeks and continues at ___. Review of Systems: As per HPI otherwise negative LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Normal right upper quadrant abdominal ultrasound. RENAL TRANSPLANT U.S. showed Normal renal transplant ultrasound. CHEST (PA AND LAT) showed Blunting of several pleural sulci could be due to small effusions or pleural scarring. There is the suggestion of tiny pleural calcifications along the diaphragmatic surface which, if present, would suggest prior asbestos exposure. Lungs are grossly clear. Nipple shadow should not be mistaken for lung nodules. Cardiomediastinal and hilar silhouettes are normal. The patient was diagnosed with ACUTE PANCREATITIS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, KIDNEY TRANSPLANT STATUS. At the time of discharge, the patient had Abdominal pain and fever. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with history of T2DM, ESRD s/p cadaveric kidney txp in ___ c/b acute cellular rejection ___, HTN, hypothyroidism p/w fever, abdominal pain, elevated lipase and transaminitis. # Fever/Lipase/Transaminitis: Most concerning for CMV given recipient CMV negative and donor positive, received Valcyte until ___ but records indicate inconsistently filled. In addition, the patient had lipase 500 with some concern for pancreatitis. Triglyercides 232, Ca normal, no history of active EtOH and remote EtOH without reported history of pancreatitis. He was given cipro/flagyl when he spiked in the morning, made NPO and given 1LNS with second liter hanging at time of discharge. Initial RUQ ultrasound is reassuring with normal pancreas head and no evidence of stone or ductal dilation, however LFT's are uptrending. CMV viral load and hepatitis serologies pending at time of discharge, the patient was given a dose of gancyclovir prior to transfer. Plan at the time was CT abd/pelvis with oral contrast only but the study was not completed. Blood and urine cultures pending at time of discharge. # DM: Sugars poorly controlled on arrival, ___ in 300's with some ketones in urine (likely starvation), no AG but bicarb 21, given 8units humalog and 30 units glargine (home dose is 40 at night) in the context of NPO, will need tight glucose attention on arrival. # Abd Pain: See above, could also be coexistant gastroparesis, got gastric emptying study read pending at time fo DC, started protonix IV. #Hyponatremia: Likely combination of hypovolemia in the setting of poor PO intake and pseudohyponatremia from hyperglycemia. Sodium corrects to 131 accounting for plasma glucose. IVF as above. #Hyperkalemia- chronic issue per records, has been on Florinef in past. Now likely ___ mild acidosis and possibly hypovolemia in the setting of pancreatitis. Improved in ED. #Hypomagnesemia: Repleted 4g IV Mg sulfate #Thrombocytopenia: Unclear etiology. ___ be ___ acute inflammation. Sequestration unlikely without evidence of portal congestion or enlarged spleen. No evidence of destruction or bleeding (consumption). Would evaluate for HIT if continues to drop though less likely. Hapto/fibrinogen normal. #ESRD s/p DDRT: DDRT ___, s/p ACR ___ which was treated with IV methylprednisone with peak creatinine 2.4. Presents with Cr 1.3 which is now baseline, tacro trough 5.0, no adjustments made to immunosuppressants. #HTN- Mildly elevated in ED and uptrending, had not received home medications all day. Cont'd Amlodipine and Aspirin 81. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Hospital Medicine Admission Note CT L-SPINE W/O CONTRAST Q331 CT SPINE showed 1. Study limited by diffuse osteopenia. 2. Transitional anatomy as described. 3. Within limits of study, no acute fracture or traumatic subluxation is identified. 4. Grossly stable multilevel vertebral augmentation, and a similar distribution to the study of ___, including some epidural cement at L1. 5. T12 and L1 stable chronic compression deformities. 6. Grossly stable multilevel degenerative changes are similar to ___ prior exam, allowing for difference in technique. Please note that lumbar spine MRI is more sensitive for the evaluation of vertebral canal neural foraminal narrowing. 7. Additional findings as described. CHEST (PA AND LAT) showed There is no focal consolidation, pleural effusion or pneumothorax. There is unchanged right basilar fibrosis/scarring. The cardiomediastinal silhouette is stable in appearance. There is a defect in the posterior aspect of the right fourth rib, which may be postsurgical. Kyphoplasty changes are seen in several lower thoracic and lumbar vertebral bodies. SECOND OPINION CT ABD/PELVIS showed 1. New lung nodules measuring up to 8 mm as compared to prior trachea CT from ___. This should be fully assessed by dedicated chest CT. 2. No evidence acute fractures within the visualized skeleton. 3. Redemonstration of an atrophic pancreas, evidence of chronic pancreatitis. 4. Patient is status post cholecystectomy and hysterectomy. CT CHEST W/CONTRAST showed Left ventricular thrombus, chronicity and clear but element of acute etiology cannot be excluded. Echocardiography is recommended. Near field areas in the posterior segment of the right upper lobe as well as basal lateral segment of the right lower lobe and posterior segment of the left lower lobe, most likely representing currently air filled bronchiectasis, cystic and less likely cavitated nodules Multiple pre-existing and some new pulmonary nodules in conjunction with mediastinal calcified lymphadenopathy might represent either ongoing sarcoidosis or combination of sarcoidosis in a typical mycobacteria. Dilated biliary and pancreatic ducts, reason unclear, correlation with MRCP is to be considered. Radiology showed Penetration with nectar thick liquids and thin liquids. Instance aspiration with thin liquids with sequential swallows. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). The patient was diagnosed with Radiculopathy, lumbosacral region. At the time of discharge, the patient had Pain after fall Hyponatremia Poorly controlled type 2 diabetes mellitus Tracheobronchomalacia Chronic pain Anxiety SIADH Cavitary lesions ___ lung LV aneurysm LV thrombus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w chronic pain, TBM, sarcoid, aspiration, chronic pancreatitis, with prior compression fractures, here with left leg pain after mechanical fall. While here was found to have SIADH, cavitary lung lesions, LV aneurysm with LV thrombus. # mechanical fall # L hip pain No evidence of syncope or even of sedation by history (though at risk for sedation as below). CT imaging at OSH and on re-read here did not demonstrate any fracture. Her pain was managed with uptitration of her hydromorphone (from 4mg to 6mg) and standing acetaminophen, physical therapy. Her pain improved with this management and has been improving almost daily. # cavitary lesions: OSH CT abd/pelvis showed concern for pulmonary nodules, for which she underwent a CT chest. Surprisingly, was found to have cavitary lesions. Pulmonary was consulted who felt that this was the result of structural lung disease history (sarcoid, prior RUL calcified nodule and bronchiectasis ___ the lower lobes upon which recurrent aspiration is resulting recurrent injury, neumonitis/pneumonia, and structural lung disease) which has resulted ___ the development of two cavitary lesions. See below regarding aspiration. It's also possible this reflects chronic infection with NTM, most worrisome would be M.abscessus and M.___, which is progressing, especially given some ___ seen ___ the anterior RML; alternatively these could reflect Actinomyces, Nocardial, or Aspergillus infections, but all thought less likely given non-toxic appearance. Finally, she has a history of sarcoidosis, and it is possible this is a cavitary sarcoid process which is slowly progressing. Underwent 3 induced sputa ___ returned with negative AFB, but as above no concern for pulmonary TB, these were sent for non-tuberculous mycobacteria), one of which showed commensal flora and staph aureus but per pulmonary this is likely just oral flora rather than staph cavitary pneumonia given how well she has been throughout pulmonary wise. Pulmonary plans for repeat interval CT/PFTs/evaluation as outpatient. They report that a positive mycobacterial culture might not even need to be treated if it occurred, but they will follow up with her as outpatient. They also recommended aggressive treatment of aspiration as below. # LV aneurysm and LV thrombus: this was found incidentally also on the CT chest. Underwent TTE which showed 1cm clot ___ LV. Cardiology was consulted and felt the aneurysm was consistent with the prior distribution of her LAD infarction, although it could be related to a stress-induced cardiomyopathy. Review of her echo, showed that she has wall motion abnormalities present after placement of the stent ___ ___. They felt sarcoidosis was not consistent as etiology. Given the apical aneurysm with associated clot, she was anticoagulated, initially w heparin gtt-->LMWH as bridge to warfarin (d1 ___, d1 ___. They recommend at least 3 months of anticoagulation (___) with repeat TTE ___ 3 months to assess for resolution of clot and presence of aneurysm. They would not recommend ischemia evaluation at this time but can consider a pMIBI as an outpatient. They advised against DOAC given not approved for this indication. # hyponatremia: appears euvolemic, worsened with IVF. Labs consistent with SIADH. Likely Likely SIADH is caused by pain, lung process. Home HCTZ was held throughout admission, pain was treated, and she had 1.5L free water restriction. With the restriction she had general improvement of her sodium, but at times she may have been drinking more than this and this led to very slight worsening of Na during last 2 days (see above for trend), though anticipate this will improve again. Suggest continued monitoring of Na, continued holding of HCTZ for now, continued free water restriction. Consider salt tabs if necessary. When SIADH resolves, can start to undo these treatments. As a result of SIADH, we did not start SSRI as below. # Hypomagnesemia: required repletion ___ house, discharged on 3 dose regimen which will end on ___ but suggest monitoring. # T2 DM: hgba1c 8.9%. Goal would not be very low given age and multiple sedating meds, but would want lower than that. Continued home Lantus 20U qd, but started aspart 3U QAC with good effect. Note that patient is not on ACE. # Hypertension: as above, held HCTZ. BP ___ normal range ___ house. Consider ACE as below. # Chronic pancreatitis: continued home creon, reglan and ppi # Chronic anxiety: was worsened ___ house, and had to increase Lorazepam to TID prn from BID prn. Would ideally want to start SSRI but given the sodium questions as above, this was deferred for now. # biliary ductal dilatation: noted incidentally on CT imaging. # dysphagia: # aspiration: Aspiration likely multifactorial and related to vocal cord dysfunction, known oropharyngeal dysphagia, multiple prior thoracic surgeries/interventions which contribute to esophageal dysfunction. Was followed by speech/swallow ___ house and underwent video swallow. This showed mild-moderate oropharyngeal dysphagia. Her swallow is most remarkable for delayed swallow response time, reduced laryngeal vestibular closure, and reduced distention and duration of the upper esophageal sphincter, with early closure and trace backflow into the pyriform sinuses. These deficits resulted ___ intermittent penetration with nectar-thick liquids and thin liquids, and frank aspiration with sequential sips of thin liquids via straw. The patient's swallow safety and efficiency were maximized using the below compensatory swallow strategies. Of note, the dilated cervical esophagus and reduced UES/PES opening was seen during previous studies. The backflow into the pyriform sinuses did not appear to impact this patient's swallow safety this date. However, further work-up with gastroenterology may be beneficial. This can be completed on an outpatient basis. On follow up, she consistently remembered to swallow 2x per bite/sip and only take single sips, but required cuing to sit upright. By the end of the meal, she recalled independently that during meals she should sit upright and demonstrated this via repositioning herself when she slouched to the L side. # tracheobronchomalacia # sarcoid No steroids indicated. We continued home Advair (unclear if actually has obstruction). Started on Acapella BID per pulm. # chronic urinary incontinence: at baseline, recommend o/p urodynamics # HLD: continued home statin. # recurrent UTI, recent yeast infection: received her last dose of fluconazole (which she had been on as outpatient) on hospital day 1. (Had already completed abx as o/p.) >30 minutes spent on patient care and coordination on day of discharge. ============= TRANSITIONAL ISSUES # Contacts/HCP/Surrogate and Communication: Name of health care ___ Phone ___ Cell ___ Date on ___ Proxy form ___ chart: No Filed on ___ Comments:Alternate: ___ (son) ___ - please wean hydromorphone back to home dose (4mg) from current 6mg as pain control improves - please wean off standing APAP as able - please continue physical therapy - sputum cx, AFB (not for TB), fungal x3 (can be followed up as o/p per pulm) - o/p ENT for dysphagia as this may be contributing per pulm - o/p GI with consideration of repeat emptying study per pulm - please have patient follow up with her cardiologist (Dr. ___ at ___ ___ ___ for repeat TTE, anticoagulation duration decision, consideration of pMIBI - please complete enoxaparin bridge to warfarin, and after therapeutic INR for 1d, can stop LMWH - after discharge from rehab, will need to be set up with an anticoagulation management clinic - monitor sodium, initially qd to qod, continue free water restriction (and reinforce), continue to hold HCTZ; consider salt tabs; stop these treatments when SIADH resolves - monitor Mg - monitor FSG and adjust DM regimen as appropriate - discuss with PCP why patient not on ACE with HTN/DM - wean Lorazepam as able (particularly at least to BID prn which is what she came ___ on) but ideally further reductions - consider starting SSRI for anxiety when comfortable from a sodium perspective - consider psychiatry, geriatric psychiatry or geriatrics to discuss pain/psych/deprescribing given fall risk - recommend o/p MRCP given asymptomatic biliary ductal dilatation - swallowing recommendations: 1. Diet: Regular solids with thin liquids 2. Pills: whole or crushed ___ puree 3. Oral care: TID 4. Aspiration precautions: - Fully upright for all PO intake - Small, single sips of liquids at a time; no chugging - Swallow x2 per bite/sip - Alternate bites and sips - recommend outpatient GI consultation to consider repeat gastric emptying and consideration of esophageal motility studies given her swallowing issues - recommend outpatient ENT consultation to consider any ENT interventions that may be helpful for her swallowing - recommend continued speech/swallow evaluations as outpatient - Acapella valve BID to help with pulmonary toilet please - please schedule patient with outpatient INTERVENTIONAL pulmonary visit with Dr. ___ at ___ (pt missed this routine follow up while admitted) - recommend outpatient gyn/urodynamics given chronic urinary incontinence - other than ___ pulmonary and ___ interventional pulmonary, patient would otherwise prefer to follow up with specialists closer to home for all issues</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx afib, recent small stroke w/ minimal residual deficit who was recently started on coumadin post stroke, transferred from ___ after falling at home with head strike and supratherapeutic INR. A head CT was negative at ___ but due to lack of neurosurgical services, the patient was transferred here. Radiology showed mpression: Right ICA<40% stenosis. Left ICA<40% stenosis. The patient was diagnosed with SYNCOPE AND COLLAPSE, HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, ABNORMAL COAGULATION PROFILE, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F with PMH significant for Afib, HTN, recent small strokes with no residual defects now on warfarin and s/p fall at home presenting from ___ for further evaluation with concern for intracranial bleed. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old male who was dining at his daughter's restaurant on the evening of admission. He had two beers with dinner and then drove home. He was found down at his door step by a friend confused and disoriented. He was brought to the ED by ambulance. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed No acute fracture or malalignment involving the cervical spine. CT CHEST W/CONTRAST showed 1. Extensive coronary artery calcification and moderate to severe aortic valvular calcifications are present. 2. Nondisplaced left anterior rib fractures involving ribs 5 through 7. There is no pneumothorax. NOTIFICATION: Updated impression regarding rib fractures and impression of likely gastric contents within the stomach discussed with the Dr. ___ telephone at 9:17 am on ___ after attending readout. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Increased left subdural collection with Ventricles remain unchanged . Basal cisterns remain patent. 2. Small foci of subarachnoid hemorrhage involves the posterior left insular region not significantly change relative to prior examination. No new hemorrhage. NOTIFICATION: Findings discussed immediately with Dr. ___ via telephone at 5:30 am on ___ at the time study was reviewed. US ABD LIMIT, SINGLE ORGAN showed No free fluid identified on this limited abdominal ultrasound. The patient was diagnosed with Traum subdr hem w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had Traumatic Subarachnoid Hemorrhage Chronic Left Subdural Hematoma Rib fractures. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old male with HLD, gout, mild dementia admitted to Neurosurgery at ___ for close neurological monitoring on ___ after a fall with loss of consciousness. He is amnestic to the event. He was found to have a chronic left-sided subdural collection and small, scattered foci of left frontal traumatic SAH. Repeat CT head revealed interval enlargement in chronic subdural collection. The patient remained Neurologically intact with only mild intermittent confusion during hospitalization, which is baseline per family report. The patient complained of anterior chest wall pain. ACS was consulted for finding of rib fractures. FAST ultrasound was performed and was negative for intra-abdominal free fluid. Pain control was recommended without further workup or investigation. Medicine was also consulted given history concerning for syncopal event, as patient does not recall the events surrounding his injury. EKG was without evidence of arrhythmia. TTE was without structural abnormalities. Orthostatics were also negative when evaluated by Physical Therapy. No further inpatient workup was deemed necessary, and the patient was instructed to follow-up with his PCP. The patient was evaluated by ___ who recommended discharge to a rehabilitation facility. The patient was discharged to rehab on ___ in stable condition. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with a PMH of CHF (EF 50-55%), severe TR, aortic regurgitation s/p bioprosthetic AVR (___) now s/p TAVR (___), CHB s/p dual chamber PPM (___), pAfib s/p failed DCCV (___) presenting with worsening shortness of breath found to be in ___ exacerbation. Elevated BNP, volume overloaded on exam. Prior hospitalization in ___ for her TAVR with 26 ___ valve via transapical approach was complicated by a tear in the left ventricle and thoracotomy for repair. She also had heart block and was implanted with a ___ pacemaker, Adapta L ADDRL1 with a ___ atrial lead 4076, and a ___ leadventricular 4076 on ___. Last checked by Dr. ___ on ___. She was discharged to rehab on post-operative day ___. Readmit for rapid atrial fibrillation and a dehisced thoracotomy incision. Discharged back to rehab. Since the surgery, has had progressive shortness of breath which is worse when lying down. Associated with bilateral leg swelling. Was seen at ___ ED, diuretics dose was increased and she was discharged. Presented for outpatient echo today and was referred to ED for progressive SOB. CHEST (PA AND LAT) showed Small left pleural effusion with associated left basilar atelectasis. Mild pulmonary vascular congestion, slightly worse in the interval. CHEST (PA AND LAT) showed In comparison with the study ___, there is little overall change in the left pleural effusion with volume loss in the left lower lobe. No evidence of pulmonary vascular congestion. The right lung remains clear. CT CHEST W/O CONTRAST showed Nonhemorrhagic left-sided pleural effusion with subsequent left lower lobe atelectasis. Mild mediastinal lymph node enlargement. Moderate cardiomegaly. Moderate coronary calcifications. Status post CABG and aortic valve replacement. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, PLEURAL EFFUSION NOS. At the time of discharge, the patient had Primary: Acute on chronic diastolic congestive heart failure exacerbation Left lower lobe pleural effusion Secondary: Atrial fibrillation Aortic stenosis s/p TAVR Aortic regurgitation Complete heart block s/p pacer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with a PMH of CHF (EF 50-55%), severe TR, CHB s/p dual chamber PPM (___), pAfib s/p failed ___ (___), and aortic regurgitation s/p bioprosthetic AVR (___) now s/p TAVR (___) who is presenting with worsening shortness of breath and lower extremity swelling with a ___ exacerbation. # Sub-acute on chronic ___ exacerbation - likely has been worsening over course of month post-procedure as patient has had difficulty breathing throughout this time period. Appeared volume overloaded on admission exam (though cannot use JVP in setting of TR), elevated BNP, R-sided disease with worsening TR and likely exacerbated by L-sided disease due to HTN and AS. SOB less likely due to pulmonary cause as no wheezes on exam and no history of URI sx or previous pulmonary disease (remote history of smoking). Recently started on lasix as an outpatient and per husband has had multiple admissions for diuresis, with intermittent improvement and then readmission. BP normal throughout admission. Given recent hospitalizations with TAVR and LV tear, also concern for arrythmias but no events on telemetry during this admission. Diuresed to dry weight with IV lasix transitioning to PO lasix, discharging on 80 mg PO lasix daily. Continued metoprolol, ASA, statin. Discharge BNP 3209. #AR s/p TAVR w/ LV tear requiring thoracotomy for repair: Continued dressing changes for left thoracotomy wound healing. Patient had two episodes of non-exertional left-sided chest/flank pain during admission without EKG changes, improved by Tylenol, attributed to wound. #Pleural effusion: Patient noted to have small left-sided pleural effusion with atelectasis on CXR, unchanged from prior CXR in ___ s/p TAVR. CT chest confirmed nonhemorrhagic left-sided pleural effusion with subsequent left lower lobe atelectasis. Interventional radiology consulted and felt it was too small to tap. As she was asymptomatic after diuresis, further intervention was not performed.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with hx of 7.6cm AAA s/p open repair via midline incision (___) and appendectomy presenting nausea, vomiting and diarrhea. He was in his normal state of health until 2 days ago when he developed these symptoms. He spent most of yesterday with nonbilious vomiting. His nausea/vomiting has improved today but he complains of continued nonbloody diarrhea. Denies abdominal pain, fever, and chills. He was hospitalized for 2 days in ___ for small bowel obstruction, which was managed conservatively on the ACS service. He denies any recent travels or changes in his appetite. CT scan was obtained today which showed evidence of a partial small bowel obstruction. CT ABD AND PELVIS W/O CONTRAST showed 1. No evidence of diverticulitis. The patient was diagnosed with Nausea with vomiting, unspecified, Diarrhea, unspecified. At the time of discharge, the patient had Partial bowel obstruction vs gastroenteritis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was Acute Care Surgery Team. The patient was found to have a possible small bowel obstruction vs gastroenteritis and was admitted for observation. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by HD2. The patient received anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The ___ hospital course was otherwise unremarkable. At the time of discharge, the patient was tolerating a regular diet, passing flatus, and voiding/moving bowels spontaneously. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ h/o SVT, HTN, HLD, anxiety, CKD, and recent admission for atrial fibrillation / flutter s/p ablation, presents with recurrent palpitations. He was discharged on ___, after undergoing flutter ablation procedure on ___. Earlier today, he developed recurrent palpitations. There was not any associated chest pain, dyspnea, nausea. He does note some diaphoresis, which he attributes to anxiety. He was initially evaluated at an OSH ED, where he was given IV diltiazem x2, w/o improvement in his tachycardia. In our ED, he was persistently tachycardic to ~150. He was evaluated by EP, who recommended holding on further CCB so that patient remains in a-flutter, with plan for repeat EPS/ablation in the AM. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with CHEST PAIN NOS. At the time of discharge, the patient had Chest pain with positive stress test. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># Unstable angina: Patient presented with anginal chest discomfort and recent positive stress test. No EKG changes at rest and cardiac enzymes negative x3. Story very atypical for cardiac chest pain given not substernal, not associated with exertion or relieved by rest. However, given positive stress test gave full dose aspirin and plavix. Given mild nature of pain at presentation, as well as ongoing nature for several days, did not give heparin. The day after admission continued aspirin at 81mg dose and added lopressor 6.25mg BID. Additionally, performed LHC afternoon of ___, which showed normal coronaries. Therefore, she was discharged late in the day. # Anxiety: Her home alprazolam 0.25mg qHS prn for insomnia was continued # OSA: Home CPAP was continued at night. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ old man with history of DM2, CAD s/p CABG ___, redo in ___, multiple stents, AS s/p core valve ___, and lumbar stenosis s/p L3-L5 laminectomies ___ and L3-L5 fusion ___ admitted from rehab with fevers. Of note, patient recently admitted to ___ ___ for revision of laminectomies and re-exploration in the setting of progressive neurogenic claudication. He had L3-L5 fusion c/b dural tear ___. Hospital course complicated by hypoxemia, angina and ___. He reports that since his discharge he has continued to have baseline low back pain which has not improved. He also reports that prior to discharge he began have loose stools. Her ports frequent bloating and flatulence. He has had 3 BM/day without blood/pus. He notes that the stools are watery. In the ED initial vitals were: 97.9 85 65/36 (repeat was 107/49) 22 96% RA. Labs were significant for WBC 13.6, Cr 2.1 (from 1.2 on recent discharge), lactate 2.3. UA unremarkable. CXR was unremarkable. Blood and urine cultures were drawn. Patient was evaluated by spine who felt medicine admission would be appropriate. EKG showed EKG: left bundle, sinus 85. Patient was given 2L IVF boluses, vancomycin, cefepime, tylenol, oxycodone. Vitals prior to transfer were:4 99.8 100 123/44 20 97% RA On the floor, patient reports mild back pain unchanged from prior discharge. He voices no further concerns. Review of Systems: (+) per HPI (-) night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed No acute cardiopulmonary process. CT L-SPINE W/ CONTRAST showed 1. Subcutaneous fluid collection at L2-3 and locules of air may be post-operative as discussed above, but correlate with recent procedures. CT has low sensitivity for infection. Within this limitation, there are no findings suggesting infection. 2. Healing fracture of the L3 spinous process. CT C-spine with contrast. showed No cervical spine fracture or malalignment NOTIFICATION: No fracture or visible fluid collection in the cervical spine. CT T-SPINE W/ CONTRAST showed 1. No findings in the thoracic spine to explain patient's fever. 2. Old left posterior 3rd rib fracture. Radiology showed Successful placement of a right 39 cm basilic approach single lumen PICC with tip in the distal SVC. The line is ready to use. The patient was diagnosed with FEVER, UNSPECIFIED. The patient was treated with ___ line placement ___. At the time of discharge, the patient had MSSA Bacteremia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o man w/ h/o DM2, CAD s/p CABG ___, redo in ___, multiple stents, AS s/p core valve ___, and severe lumbar stenosis s/p L3-L5 laminectomies in ___ who represented to ___ on ___ for revision of laminectomies and re-exploration in the setting of progressive neurogenic claudication, s/p L3-L5 fusion c/b dural tear intraoperatively on ___, recently discharged, returning with back pain and fever of unknown origin, found to have MSSA bacteremia. # MSSA acute blood stream infection with sepsis: On presentation, patient met ___ SIRS criteria for fever, respiratory rate and leukocytosis with neutrophil predominance. Given a complaint of diarrhea, C diff was sent, but came back negative. Blood cultures on ___ grew methicillin-sensitive staph aureus so patient was narrowed to Nafcillin 2g IV Q4H, ___ dose ___. WBC trended down to 6.7 by discharge. Given patient's pacemaker was incompatible with MRI, we proceeded to do a CT scan with contrast, premedicating him with benadryl, prednisone, and IVF per protocol (over 13 hours) given his documented anaphylactic allergy to contrast agents. He tolerated the dye without incident. CT of his L spine with contrast on ___ showed subcutaneous fluid collection and pockets of air, likely postoperative changes though cannot exclude underlying infection given limitations of image modality. An aspiration of the fluid pocket was negative for growth on culture. Urine and sputum cultures, as well as multiple daily surveillance blood cultures following treatment, were negative. Patient remained afebrile throughout the rest of his hospital course, with no focal neurological symptoms, though with notable weakness in R lower extremity, which per him, predated his surgery. TEE on ___ showed 1+ mitral regurgitation, with no vegetations noted on aortic ___. Our neurosurgery and infectious disease teams saw and evaluated the patient throughout his hospitalization, with recommendations to continue his Nafcillin via a PICC line placed on ___ for a minimum of 2 week course. He will follow-up with Infectious Disease on ___, who will consider need for repeat imaging to assess the fluid collection. Of note, if he is imaged w/ contrast dye, he will need to be premedicated again. # Spinal Stenosis s/p L3-L4 fusion: Patient underwent revision laminectomies by neurosurgery on ___ with intraoperative complication of dural tear which was repaired. His back pain was maintained on PRN Oxycodone ___ Q4H with good effect. Our physical therapy team also saw and evaluated him while inhouse. Per neurosurgery, staples will come out on ___, and have instructed he wear his TLSO brace when out of bed. # ___: Patient initially presented with BUN of 49, creatinine of 2.1 on admission ___ Cr is 1.2). He had a foley placed on admission given h/o urinary retention and was given gentle fluid rescuscitation given his history of CHF. We also held his lisinopril, renally dosed his meds, and trended his kidney function and urine output. His kidneys responded well, with a BUN to 20, and Cr to 0.9 at discharge. On discontinuing his foley, he failed a void trial so foley was replaced which will be managed at his rehab. # Urinary retention: urinary retention prior to admission, w/ foley placement. Has h/o BPH. We did a due to void trial on ___, which he failed, and foley was replaced. Should have ongoing trial of foley removal at rehab, with follow-up with a Urologist as needed if unable. We continued avodart, tamsulosin. # COPD/OSA: This was stable, without significant wheezing during this hospitalization. He required no O2 during this hospitalization. We also had PRN dual nebs, continued his home theophylline, had him on continuous O2 monitoring, and placed him on CPAP at night (though he declined use on several occasions), and he remained stable throughout his hospital course. # chronic diastolic CHF: Last ECHO in ___ showed EF 35%. Repeat ECHO on ___ showed EF stable at 35%, with no vegetations on his valve. We held her metolazone, torsemide and lisinopril in the setting of ___. Per patient, his metoprolol was discontinued in the past because of severe hypoglycemia and hypotension but we restarted a small dose of metoprolol succinate (12.5mg) given his extensive cardiac history. We also sent a lipid panel, and started simvastatin 10mg daily. We strictly monitored his fluid input and output, monitored him on telemetry and repleted his lytes as needed. #) Volume status: he has previously been on torsemide 40mg QOD, 60mg QOD, and metolazone 2.5mg daily. Given ___, these diuretics were stopped. He continues to have poor PO intake and is euvolemic on exam, so we are sending him to rehab off of diuretics, to be restarted as needed in the outpatient setting. # s/p PPM for AV Block: Patient had a ___ model ___ dual-chamber pacemaker which was non compatible with MRI. The implant date of this pacemaker was ___. We monitored his cardiac function on telemetry throughout his hospital course. # History of lupus anticoagulant on Coumadin: Coumadin was held at prior discharge and per neurosurgery, could be restarted 10 days post op (___). However, this was held during this admission given his INR was elevated, likely secondary to poor nutrition and ongoing bloodstream infection with antibiotics. His INR eventually stablized to 2.0 on discharge and we restarted his regular coumadin dose with plans to continue his routine INR checks at his outpatient ___ clinic. Next check ___, dose adjustment per rehab doctors. # DM2, controlled without complications: blood sugars ran low in 60-70's AM, so we decreased NPH dose from 25 units BID to 22 units BID. Diabetic diet. # Hypothyroidism: This was also stable, and we continued Levothyroxine at her regular home dose # Code status: Full code # Emergency Contact: ___ (Wife/HCP) ___ home Wife cell # ___ TRANSITIONAL ISSUES # Continue receiving antibiotics through your ___ line till ___ for a total 2 week course till you see the infectious disease team as scheduled. ID may continue the total course of antibiotics when they see you on ___. Consider re-imaging of pocket. # If he gets ___ need iodine contrast allergy prevention, per ___ PPGD guideline # INR and chem 7 to be checked on ___. Coumadin to be managed by rehab physicians. # Please have the staples in your back removed on ___, ___, by rehab # TLSO brace at all times when out of bed, until follow-up with Neurosurgery # Restart diuretics as needed in the outpatient setting </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of hepatitis C status post Harvoni, with cirrhosis and varices presenting with palpitations x3 days. Radiology showed 1. Hazy appearance of the abdomen with centrally located air-filled bowel loops suggestive ascites. No evidence of obstruction. 2. Left basilar opacity could represent atelectasis and effusion, however, underlying airspace disease cannot be excluded. 3. Postsurgical changes from prior TIPS, coiling, and IVC filter. 4. Stable cardiomegaly. DUPLEX DOPP ABD/PEL showed 1. Evaluation of the TIPS is limited in the postoperative day 2 setting. Color flow is seen in the main and proximal portions of the TIPS, but velocities are 8.04 and 55.6 cm/sec, respectively. The distal TIPS is not evaluated, as it is obscured by shadowing. 2. Small echogenic focus in the posterior right portal vein may indicate a small thrombus (see series 1 a, image 3435). 3. Trace ascites an a small right pleural effusion. RECOMMENDATION(S): Close interval imaging follow-up is recommended. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 09:44 on ___, 5 min after discovery. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. CHEST (PORTABLE AP) showed As compared to ___ chest radiograph, cardiac silhouette has decreased in size and pulmonary edema has nearly resolved. A nonspecific left lower lobe opacity has partially cleared and bilateral pleural effusions have decreased in size. DUPLEX DOPP ABD/PEL showed Elevated velocities within the visualized portions of the TIPS. Directionality of flow in the right and left portal veins has changed and is noted to be away from the TIPS. Increased ascites. These findings are concerning for a distal TIPS stenosis. NOTIFICATION: Findings concerning for TIPS stenosis were discovered at 09:05 on ___ and were conveyed by telephone to Dr. ___ by Dr. ___ approximately 10 min after discovery. DUPLEX DOPP ABD/PEL PORT showed 1. Patent hepatic vasculature. 2. Cirrhotic liver with moderate ascites, moderate right pleural effusion, and splenomegaly. No suspicious focal liver lesion. CHEST (PORTABLE AP) showed Opacities, which are seen predominantly in the right mid and lower zones and, densely, in the left lower lobe. While this could represent asymmetric pulmonary edema, the possibility of a superimposed infectious consolidation cannot be excluded. Upper zone redistribution on the left is noted. On the right, the vessels are obscured by surrounding opacities. Possible small bilateral pleural effusions. CHEST (PORTABLE AP) showed Cardiomediastinal silhouette appears larger, but is likely accentuated by lordotic positioning. Findings compatible with pulmonary edema, including bibasilar alveolar opacities. Possible minimal interval improvement at the right base. As before, the presence of superimposed infectious consolidation at the lung bases, particularly on the left, would be difficult to exclude. Radiology showed Right PICC terminates in the region of the cavoatrial junction -- please see comment above. No pneumothorax detected. Bibasilar opacities are similar to before which may reflect atelectasis, however pneumonia is difficult to exclude. CT abdomen pelvis without and with contrast showed 1. Cirrhosis, splenomegaly, and mild ascites. Esophageal and gastric varices. No suspicious lesion. 2. Cardiomegaly. 3. Bibasilar atelectasis. Moderate right and small left pleural effusions. Radiology showed Successful right internal jugular access with transjugular intrahepatic portosystemic shunt placement and variceal sclerosis/embolization with decrease in porto-systemic pressure gradient from 14 mmHg to 6 mmHg. RECOMMENDATION(S): The patient will need an outpatient TIPS venogram in 1 month to assess for any residual varices and further embolization. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified, Non-ST elevation (NSTEMI) myocardial infarction, Unspecified cirrhosis of liver. The patient was treated with EGD ___ Diagnostic Paracentesis ___ TIPS ___. At the time of discharge, the patient had Primary Diagnoses ===================== Anemia Variceal Bleeding s/p TIPS NSTEMI Acute on chronic diastolic heart failure HCV Cirrhosis Acute kidney injury Sinus bradycardia Secondary Diagnoses ===================== Hypertension Hyperaldosteronism History of CVA c/b seizures Vitamin D deficiency Prolonged QTc. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male with history of Hep C cirrhosis c/b varices s/p Harvoni, diastolic heart failure with recent admission at OSH requiring intubation, presenting with symptomatic anemia ___ variceal bleeding now s/p TIPS, course complicated by demand NSTEMI, bradycardia, and ___. #HCV cirrhosis s/p sustained virologic response complicated by variceal bleeding: Pt had a prior known history of esophageal varices s/p banding. He presented with dyspnea and chest discomfort and was found to have Hgb of 5 at ___ on ___. He was transferred to ___ for further evaluation, and EGD revealed extensive gastric varices with signs of recent bleeding. He received a total of 4 units pRBCs. He was unable to tolerate beta blocker for bleeding prophylaxis (see below). The patient was treated with PPI BID, and received IV Ceftriaxone for SBP prophylaxis. Diagnostic paracentesis fluid cultures grew coagulase negative staph in only 1 bottle, and this was thought to be a contaminant and treatment was discontinued. The patient underwent TIPS via R IJ approach on ___ with improvement with improvement in portosystemic gradient from 14 to 6 mmHg. Additionally during the procedure the patient had sclerosis/embolization of varices. His Hgb remained stable for the duration of his remaining hospitalization. The patient developed some abdominal pain post TIPS, and serial RUQ US revealed findings concerning for possible TIPS stenosis, however imaging of TIPS limited in the immediate post procedural follow up. The interventional radiology team who performed the TIPS procedure evaluated the images, and recommended repeat venogram in 1 month for follow up, and that there were not concerning findings requiring immediate intervention. An HCV VL was sent during the admission which was negative. #Symptomatic bradycardia: Pt received a dose of 20mg nadolol and developed sinus bradycardia with rate of 30. He was also relatively hypotensive to SBPs ___ and felt nauseated. He required dopamine support to maintain HR and BP for nearly 48hrs after nadolol was discontinued. Pt reported having similar symptoms with propranolol in the past. EP was consulted for consideration of PPM, and they felt this would be a possibility if there was a strong indication for beta-blockers for his varices. Hepatology did not recommend beta blockers for this current hospitalization. Beta-blockers were added to his allergy list. Ocreotide was also held due to concern for bradycardia as a potential side effect. Off beta blockers, the patient had no further episodes of bradycardia on the Liver floor. #NSTEMI: Likely type 2 due to demand ischemia and severe anemia. Troponin peaked at 0.35 and downtrended after transfusions. He was started on high dose atorvastatin but aspirin was held due to bleeding risk and beta blocker held as above. Low dose lisinopril was started prior to discharge. Outpatient cardiology follow up was set up prior to discharge, and the patient will need CAD evaluation. #Low grade fever: While on the Liver floor the patient developed a low grade fever 10 100.1. CXR unremarkable, recent ___ US negative for DVT. UA with pyuria though initial culture negative. There was not evidence of leukocytosis or hemodynamic instability, and the patient remained afebrile for the remainder of the hospitalization. The patient was asymptomatic. A repeat urine culture was sent one day subsequent to the prior negative culture and returned positive for ___ stenotrophomonas maltophila after the patient had been discharged from the hospital. #Acute on chronic diastolic CHF: Volume overloaded on exam at admission. He was diuresed with furosemide IV boluses and metolazone. The patient had not been on any diuretics prior to admission, but was transitioned to PO torsemide prior to discharge. He was continued on hydralazine for afterload reduction, and low dose lisinopril was started with improvement in ___. Home imdur was held, and the patient was not discharged on a beta blocker due to above symptomatic bradycardia. ___: Cr increased from 0.9 to 1.7. Improved with blood transfusion and urine studies were consistent with pre-renal azotemia. Thought most likely in setting of hyperperfusion given low BP and venous/portal hypertension in volume overloaded state. Improved with diuresis in the MICU. The patient had a slight bump in creatinine with re initiation of diuresis on the Liver floor that resolved. # LLE swelling and pain: Patient reported left lower extremity swelling and pain over patella and to palpation of shin. ___ negative for DVT. No clinical evidence of infection. Pain resolved, and asymmetric edema appears chronic secondary to prior CVA. ======================= CHRONIC ISSUES ======================= #Hyperaldosteronism: Home epleronone restarted s/p EGD with improvement in ___, electrolytes. #History of CVA c/b seizures: The patient was continued on home lamotrigine. #Psych: The patient was continued on home escitalopram. #Vitamin D deficiency: Patient continued on home vitamin D. #Prolonged QTc: QTc trended and improved prior to discharge. ======================= TRANSITIONAL ISSUES ======================= # Weight on discharge: 77.3 [ ] Will need TIPS venogram in 1 month to assess for pressures studies and evaluation of varices [ ] Please obtain electrolytes on ___ and ___ - Na, K, HCO3, Cl, BUN, Cr, Ca, Mg, Phosphate - ensure results faxed to PCP ___ at ___ at ___ [ ] Consider titration of diuresis pending electrolytes and weights [ ] Consider starting Aspirin at cardiology follow up [ ] Consider uptitration of lisinopril at PCP/cardiology follow up pending electrolytes [ ] Consider restarting Imdur at next PCP/Cardiology visit pending blood pressures [ ] No beta blockers or ocretotide given bradycardia [ ] Care with QTc prolonging medications, would obtain EKG for QTc monitoring prior to starting any new QTc prolonging medications [ ] Outpatient workup for CAD [ ] Ensure follow-up with PCP, ___, ___, and cardiology [ ] A repeat urine culture was sent one day subsequent to the prior negative culture and returned positive for ___ stenotrophomonas maltophila after the patient had been discharged from the hospital. If symptomatic, please treat appropriately. CODE STATUS: FULL CODE</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o woman with a PMH of CAD (s/p silent MI, c/b LV thrombus on warfarin), splenic infarction, HFrEF (LVEF=35%), COPD, recently discharged from ___ on ___, who re-presents with persistent SOB. She reports at least one week of dyspnea with intermittent wheezing. She was seen at ___ and was thought to have pneumonia, heart failure exacerbation, and COPD exacerbation. She reports that she received three days of steroids and antibiotics at the hospital. She was discharged with a course of steroids, which completed today. She reports that since then, her symptoms have persisted. She reports a cough and feels as though there is phlegm in her chest that she is unable to bring up. She has been taking her Lasix, 20 mg once a day, without missing any doses. She denies fevers but does endorse chills. She reports dyspnea on exertion, without orthopnea or PND. She denies chest pain. She endorses RUQ abdominal pain with one dark bowel movement, without hematochezia. She denies dysuria, hematuria, constipation, or diarrhea. Chest: Frontal and lateral views showed Bilateral hilar engorgement with hazy bilateral diffuse opacities concerning for pulmonary edema. Small bilateral pleural effusions. No definite focal consolidations are seen, however post diuresis views could be obtained as clinically indicated. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Gravel-like cholelithiasis without evidence of cholecystitis or biliary dilatation. The patient was diagnosed with Heart failure, unspecified, Dyspnea, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS: ================== - Acute heart failure with reduced ejection fraction - LV thrombus - Cholelithiasis SECONDARY DIAGNOSIS: ==================== - CAD - Tobacco use - COPD - Microcytic anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o woman with a PMH of CAD (s/p silent MI, c/b LV thrombus on warfarin), splenic infarction, HFrEF (LVEF=35%), COPD, recently discharged from ___ on ___, who re-presents with persistent SOB. #CORONARIES: multivessel disease, no stenting or PCI #PUMP: LVEF=35% #RHYTHM: Normal sinus rhythm</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old male who complains of ___ male who is here for one week of intermittent fatigue, fevers. They had a 20 minute episode of discomfort across the chest that was associated with a fever to 102. The discomfort lasted for about 20 minutes and has not recurred. He denies having any abdominal pain, vomiting, reports no bowel movement for 5 days but is passing gas. Also feels like he has been a little bit unsteady on his feet, contrary to resident note the patient denies any mumbling speech just says his mouth has been dry. Radiology showed 1. Distended gallbladder with mural thickening, sludge and gallstones. There is no apparent pericholecystic fluid or sonographic ___ sign. While mural edema is nonspecific and can also be present with cardiac dysfunction, hypoalbuminemia and hepatic dysfunction, in the appropriate clinical setting, this appearance can also be consistent with acute cholecystitis. HIDA can be obtained for further assessment if indicated. 2. Trace perihepatic free fluid. The patient was diagnosed with FEVER, UNSPECIFIED, OTHER MALAISE AND FATIGUE, CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with ___ Laparoscopic to open cholecystectomy. At the time of discharge, the patient had Primary diagnosis: acalculus cholecystitis Secondary diagnosis: A-fib Diabetes Mellitus 2 Coronary artery disease Constipation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of afibrillation presented with sudden-onset chest pain, increasing right upper quadrant tenderness, and generalized weakness for the last 8 days. Clinical picture concerning for acute cholecystitis. Since there was concern for acute coronary syndrome, troponins were cycled x 3 which were normal. The patient underwent a ultrasound which showed gallstones and slugde which could be consistent with acute cholecystitis. On blood work, he was noted to have an elevated alkaline phosphatase. He underwent serial abdominal examinations which remained stable. He then underwent a HIDA scan which was normal and showed no cholecystitis. However, his white blood cell count continued to rise with reported increased in right upper quadrant pain. He was started on intravenous ciprofloxacin and flagyl. Because of these findings, he was evaluated by the acute care service. On HD # 4, he was taken to the operating room where he underwent a cholecystectomy. He was reported to have acute gangrenous cholecystitis with a pericholecystic abscess.At the close of the procedure, he had ___ drain placed into the galbladder fossa. His operative course was stable with minimal blood loss. He was extubated after the procedure and monitored in the recovery room. His post-operative course has been stable. THe swab from the gallbladder grew E.coli. The patient remainded afebrile and his white blood cell count normalized. After bowel function returned, he was started on clears and advanced to a diabetic diet. His incisional pain was controlled with intravenous analgesia with a conversion to oral agents. He was voiding without difficulty. He was evaulated by physical therapy and they determined that no acute needs were evident and that when medically stable, the patient could be discharged home. The ___ drain was removed on ___ and the patient was discharged home in stable condition. Follow-up appointments were made with the acute care service and with the primary care provider. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a pleasant ___ F with a history of hyperparathyroidism (s/p 3.5 gland parathyroidectomy in 2000s at ___), obesity s/p bariatric surgery presents transferred from ___ for work-up of presumed first seizure. MANDIBLE (PA, ___ AND ___ OBLS) was done. MR HEAD W AND W/O CONTRAST showed 1. The examination is suboptimal secondary to patient motion artifact. 2. Allowing for this limitation, there is no evidence of intracranial mass, acute hemorrhage or infarct. 3. No gross evidence of gray matter heterotopia or abnormalities of the mesial temporal cortex. 4. If remains high clinical concern, dedicated seizure protocol MRI with contrast may be performed. 5. Air-fluid level in the right maxillary sinus. This may be seen in acute inflammatory process such as acute sinusitis. Clinical correlation is recommended. The patient was diagnosed with JAW PAIN. At the time of discharge, the patient had Primary diagnosis: - Syncope - Right inferior orbital fracture - Hypophosphatemia - Hypomagnesemia - Hypovitaminosis D. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F with history of hyperparathyroidism (s/p parathyroidectomy), obesity s/p bariactric surgery who presents after being found down with bystander report of convulsions concerning for first seizurea. #) SYNCOPE: Sudden syncopal event without prodrome and subsequent confusion is suggestive of seizure activity with post-ictal period; this was considered a provoked seizure in the setting of hypophosphatemia. However, it appears ___ record of low phosphate was likely inaccurate (see below) and thus if this truly was a seizure it was not a "provoked" seizure. Further, second/third-hand report of convulsions by non-medical observers may be unreliable. No evidence of cardiac cause of syncope (EKG/tele normal), or dysautonomia (orthostatics negative.) MRI head negative for pathology ___ (although not "seizure protocol" so should have this repeated as an outpatient.) EEG without epileptiform activity. Neurology was consulted and did not recommend anti-epileptics. A follow-up appointment was arranged with Neurologists of ___ to consider further work-up. She was advised that she cannot drive for 6 months. #) HYPOPHOSPHATEMIA: Documented value at ___ was 0.8 and she received IV repletion there. Did not recur at BI in absence of repletion, bringing into question accuracy of this lab value at ___. Further, there were no other stigmata of hypophosphatemia (ex. elevated CK from rhabdo which you would expect at a level that low.) Upon arrival, urine phosphate was high (FEPhos 27% on ___. Serial measurements of phosphate and magnesium where normal at ___ without any supplementation whatsoever. Repeat urinary phosphate on ___ was normal (FEPhos 5%) A normal FEPhos is ___. Thus her initial phos-wasting urine studies may have been physiologic if she received an inappropriate load of IV phosphate at ___ when she was believed to be truly hypophosphatemic. Her PTH was normal at 45 and calcium was normal. Vitamin D was low but in isolation this does not explain a reported phosphate of 0.8. Repeat electrolytes should be checked as an outpatient. #) HYPOMAGNESEMIA: Reported mag at ___ was 1.1. Similar story as with phosphate as above; No evidence of hypmagnesemia at ___ on serial measurements. EKG with normal QTc. Likely a lab error at ___. Should be re-checked as an outpatient. #) MANDIBULAR DISLOCATION: Reduced in ED with MAC (ketamine) #) FACIAL FRACTURES: Nondisplaced fractures of the right orbital floor. Right maxillary wall fractures and hematoma within the right maxillary sinus. OMFS was consulted in the ED, who recommended non-surgical management with pain control and ice packs. She had anesthesia in the right infra-orbital nerve distribution likely representing nerve damage from the above injuries. She was given the outpatient follow-up information. #) DEPRESSION: Continued home venlafaxine and escitalopram. #) LOW BACK PAIN: Continued home oxycodone and fentanyl patch. Held celecoxib since non-formulary #) INSOMNIA: Continued home zolpidem, lorazepam. # CODE STATUS: Full (confirmed) # CONTACT: ___ (husband) ___, ___ (sister/HCP) ___ TRANSITIONAL ISSUES =================== [] F/U with outpatient neurology and consideration of MRI with seizure protocol [] Repeat electrolytes including Ca, Mg, Phos as outpatient - No driving x 6 months</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo man with a history of recurrent/advanced ___ s/p chemo/XRT, cardiomyopathy (unclear Radiology showed Right hilar mass and paramediastinal post treatment changes are unchanged since ___. A small to moderate subpulmonic right pleural effusion has increased since ___. Radiology showed 1. No evidence of pulmonary embolism. 2. Unchanged right hilar and paramediastinal post-treatment changes. 3. Slight interval decrease in size of right upper paratracheal mass compared to the prior study. 4. Mucoid impaction in the left lower lobe airways, with an 8-mm endoluminal filling defect in the left lower lobe bronchus which could be a chronic mucus plug; however, attention on followup imaging is recommended to exclude malignancy. 5. Extensive venous collateralization along the left chest wall and paravertebral regions due to narrowing of the left brachiocephalic vein, advanced since the prior study. 6. 2.8 cm left supraclavicular soft tissue nodule is concerning for metastasis. 7. Stable appearance of aortic arch pseudoaneurysm, as described above. Radiology showed 1. No acute intracranial abnormality. 2. Small metastases are better assessed with MRI. 3. Chronic left basal ganglia infarct is unchanged. The patient was diagnosed with RESPIRATORY ABNORM NEC, TACHYCARDIA NOS, HYPOXEMIA. At the time of discharge, the patient had PRIMARY: non-ST-elevation myocardial infarction, Non-small cell lung cancer SECONDARY: Chronic systolic heart failure, hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old gentleman with advanced NSCLC and cardiomyopathy of unclear etiology with EF 40%, who presents with chest pain and dyspnea, found to have an NSTEMI. ACUTE ISSUES # NSTEMI: The patient received medical management of his NSTEMI given his life-limiting illness and poor prognosis with advanced malignancy. He was started on a heparin drip and received Enoxaparin to complete 48 hours of anti-coagulation. He was also started on metoprolol for a heart rate goal <70, and SL nitro PRN chest pain. His home statin was switched to Atorvastatin 80mg. He was also further evaluated with a cardiac echo which revealed an improved left ventricular function from prior and a stable pericardial effusion. By morning of admission, the patient was chest pain free and denied chest pain throughout his hospital stay. # Pericardial effusion: The patient was noted to have a small pericardial effusion on CT imaging. A cardiac echo revealed a small to moderate sized pericardial effusion without echocardiographic signs of collapse. # Cardiomyopathy The patient has a known cardiomyopathy with an EF of 40% on echo from ___. He was euvolemic on exam despite an elevated BNP. His chest CT did not show evidence of pulmonary edema, and a repeat cardiac echo showed an improved EF of 50-55%. He was maintained on his home Lisinopril 2.5mg daily, and his home furosemide was initially held and then restarted on discharge. # R pleural effusion: The patient was noted to have a right pleural effusion, increased in size from prior imaging. His dyspnea improved with resolution of his chest pain, and he was satting well on RA. Thus further work up of his right pleural effusion was deferred. CHRONIC ISSUES # NSCLC: The patient's CTA demonstrated stable appearing paratracheal and paramediastinal masses. He was continued on his home inhalers and should follow up with his out-patient oncologists. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with poorly controlled asthma, bronchiectasis, history of positive PPD and tobacco use presents with shortness of breath. The patient has had a complicated course over the last couple of years with exacerbations requiring frequent steroid tapers, antibiotics and hospital admissions. She has at least two ICU stays with one intubation and one bipap. Over the last few weeks, she reports worsening shortness of breath again. She was prescribed a steroid taper that started around ___. She reports improving on the 40mg dose, but by the time she tapered to 10mg, the symptoms has started again. She increased herself back to 30mg prednisone for 2 days on ___ and ___ but then stopped completely because she was out of medication and did not have any refills. So she has been without steroids since ___. Radiology showed 1. Overall improvement of bronchial wall thickening and mucous plugging. Marginally more prominent ___ opacities in right upper lobe suggestive of small airways disease in light of other findings. 2. Pulmonary nodule in the left lower lobe laterally, similar to prior exam. Recommend follow-up CT chest in one year if she has risk factors. Updated findings from wet read were communicated to Dr. ___ at 11:05 p.m. on ___ by phone. Radiology showed No focal consolidation. The patient was diagnosed with SHORTNESS OF BREATH. At the time of discharge, the patient had 1. asthma exacerbation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with poorly controlled asthma, bronchiectasis, history of positive PPD and tobacco use presents with shortness of breath. # Asthma exacerbation - Most likely due to discontinuing home prednisone and non-compliance with medications. We initially placed pt on solumedrol 125mg Q6hr x2 days and further transitioned her to prednisone 40mg. However, patient's symptoms and lung exam worsened upon transitioning to prednisone and thus, taper may have been too quick for her. We resumed solumedrol 125mg Q6hr x2 days, then tapered to 80mg Q8 x1 day and then to prednisone 60mg daily with the following taper: 60mg x5 days, 50mg x3 days, 40mg x3 day, 30mg x3 days, 20mg x3 days, 10mg until f/u with Dr. ___. We also treated her with levofloxacin for total of 7 days, last dose on ___. Per pulmonogy recommendation, we initiated azathioprine 50mg daily upon discharge upon normal LFT's, negative hepatitis serology, and negative serum HCG. Given concern for EGPA on behalf of primary pulmonologist, we consulted rheumatology who believed that current presentation is unlikely to be due to EGPA given lack of symptoms suggestive of vasculitis and other systemic involvement. We also initiated bactrim for PCP ___. There was evidence of thrush due to chronic steroid use and patient was started on nystatin mouth wash. The following were found on outside hospital records: IgE 181 and ESR 34. # hand and leg pain/numbness - Peripheral neuropathy is a common presentation in EGPA but usually presents as mononeuritis multiplex, or as peripheral neuropathy in "stocking and glove" distribution. Her presentation is more c/w radicular vs. vasculitic. - outpatient f/u w/ neurology as previous work-up suggestive of cervical stenosis, had recommended MRI. - Rheum consult as above # pulmonary nodules - unclear significance - radiology recommends f/u study with CT in ___ year. TRANSITIONAL ISSUES: [] neuropathy of ___ - has appointment scheduled with neurology as there is concern for radicular neuropathy [] hypertension: pt hypertensive to 150's/100's throughout hospital course. Currently, on no antihypertensives. Renal function normal. [] attention to follow-up regarding LLL pulmonary nodule noted on chest CT dated ___ [] please schedule close follow-up (within ___ weeks) with Dr. ___ pulmonary) and with PCP [] drug monitoring as above [] follow-up pending studies as above [] follow-up blood glucose level as outpatient while on steroid therapy [] Has received pneumonia vaccine in ___ at ___ and flu vaccine on ___. Will need prevnar at clinic follow-up when on lower dose of steroids</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo man with recently diagnosed metastatic LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT showed 1. No intrahepatic biliary duct dilation. Unchanged appearance of the common bile duct stent, with pneumobilia suggesting the stent is patent. 2. Collapsed gallbladder with wall thickening, which is nonspecific. There is a small amount of curvilinear foci of fluid around the gallbladder but no discrete drainable fluid collection. Residual inflammatory change in this region is not excluded. 3. Pancreatic head mass and liver metastases, which were better characterized on the prior MRI. Radiology showed Small bilateral pleural effusions and bibasilar atelectasis. No definite pneumonia. MRCP showed No significant intraabdominal change status post removal of percutaneous cholecystostomy tube. No evidence of recurrent acute cholecystitis or collection. Pancreatic head tumor with local vascular involvement, and diffuse hepatic and nodal metastases, unchanged from recent priors. Slight increase in bilateral pleural effusions. Subpleural parenchymal nodules are visualized in regions of prior consolidation. These could represent residual consolidation or metastases. The patient was diagnosed with FEVER, UNSPECIFIED, MALIG NEO PANCREAS NOS. At the time of discharge, the patient had Pancreatic cancer Fever History of biliary obstruction s/p bile duct stenting and percutaneous cholecystostomy tube now removed History of multi-drug resistant pseudomonas. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ hx HIV recently started on HAART, recently dx metastatic panc CA c/b biliary obstruction s/p CBD stent and recently removed perc chole tube, who presents from ED w/ recurrent fever. # Fever with SIRS: Remained HD stable since IVF bolus in ED. Given pt hx concerning for recurrent cholangitis/cholecystitis or liver abscess although no WBC elevation, GB not thickened on U/S and no RUQ pain. Also possible recurrent pseudomonas bacteremia but no signs of sepsis since admission. - given vanco/tobra in ED but did not cont as tobra led to renal insufficiency in recent past and no hx MRSA or other indication for vanco at this time - pt was resumed on ceftolazone/tazobactam to cover prior MDR pseudomonas (had been stopped on ___ however cx neg for 48 hrs, stopped am ___ - no further fevers off antibiotics. Liver U/S and MRI without signs of cholecystitis/cholangitis. - discussed w/ ___, no plans for replacement of drain given stable imaging During his admission was noted to have nightly temp elevation ___, reports some night sweats at home. suspect fevers prior to admission may have been related to underlying malignancy #Anemia - symptomatic w/ fatigue. possible chronic blood loss w/ iron def as there was some invasion of duodenum by panc mass on last ERCP in ___ but no ulceration or bleeding at that time. iron studies this admission more c/w ACD, is able to mount some reticulocytosis. - hapto/LD normal - mod low iron, elevated ferritin, low TIBC more c/w ACD than true iron def - hgb declined to 6.7 after IVF on admission, pt received total 2U PRBCs ___ and ___ - guiac stools x 3 negative #Renal insufficiency - timing c/w prior tobra nephrotoxicity, has been slowly improving, Cr 1.2 on discharge (prev up to 1.9) # Right PICC-assocd DVT: RUE U/S positive for DVT on ___. PICC removed, swelling has resolved. Cont on daily lovenox. # Pancreatic adenocarcinoma: Followed by Dr ___ w/ ___. Chemotherapy has been delayed due to mult prior infectious complications. per Dr ___ like him to be off antibiotics for 2 weeks prior to starting therapy. Other than 48 hrs antibiotics this admission, last antibiotic course ended ___. He will f/u w/ Dr ___ week # HIV: recently initiated HAART w/ triumeq. Per ID notes is long term nonprogressor. Last known CD4 313 & viral load 20K on ___, recently started receiving HIV care by Dr ___ at ___. triumeq continued while inpt PAIN: cont home oxycodone BOWEL REGIMEN: cont home regimen senna/docusate increase miralax to daily (was prn)</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old man with recently diagnosed high-grade soft tissue sarcoma of the right upper arm who was transferred to ___ with bleeding from his tumor and plan to urgently initiate radiation treatment. MRI right arm with and without contrast showed Since ___, there has been marked increase in size of the large, predominantly solid mass in the anterior soft tissues at the level of the distal humerus compatible biopsy-proven high-grade pleomorphic sarcoma. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. BILAT UP EXT VEINS US showed 1. Patent deep veins of the bilateral upper extremities without evidence of deep vein thrombosis identified. 2. Bilateral supraclavicular soft tissue edema without focal abnormalities. Radiology showed Successful placement of a double lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. The patient was diagnosed with Malig neoplm of conn and soft tiss of l upr limb, inc shldr. The patient was treated with POC placement ___. At the time of discharge, the patient had # High grade sarcoma # Anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PRINCIPLE REASON FOR ADMISSION: =============================== ___ is a ___ year old man with recently diagnosed high-grade soft tissue sarcoma of the right upper arm who was transferred to ___ with bleeding from his tumor and plan to urgently initiate radiation treatment. # High grade sarcoma: His external bleeding has stopped, and he initiated his first session of radiation on ___, which he continued daily through ___. We prepared to start concurrent doxorubicin next week with TTE and obtained POC access. Ultimate plan for 4 additional weeks of neoadjuvant chemoradiation prior to surgical evaluation. He will return to 11R on ___ morning to resume concurrent chemoradiation. # Hemorrhage: # Anemia # B12 deficiency: Superficial hemorrhage of fungating tumor resolved. He also has areas of internal hemorrhage in the tumor. CTA showed no active extravasation, and HCT stayed generally stable. Also found to be B12 deficient, likely nutritional. We started 1000mcg B12 daily with MVI and folate. MMA is pending on discharge. # Cancer associated pain: Due to severe cancer associated pain, with high oxycodone requirement, he was started on Oxycontin. We titrated the dose to 30mg q12 hours along with 10mg po oxyocodone q4 hours as needed. ___ benefit from palliative care consult in future admissions. # Edema: Doppler US negative for clots. Improved after restarting home HCTZ. # HTN: Restarted home HCTZ and home lisinopril 20mg bid # Coronary artery disesea: No known clinical CAD, but CT on ___ noted proximal LAD atherosclerotic calcification. TTE was normal. Consider outpatient stress testing. # Billing> >30 minute spent coordinating and executing this discharge plan</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo M with a h/o HIV (CD4 1270, Viral Load <75 on ___ here with acute onset RUQ abdominal pain with radiation to the epigastrium. Patient states that this 'gnawing' pain woke him out of his sleep at 2am this morning and was constant ___ severity. Tried naproxen with no relief. No alleviating/aggrevating factors. Pain was associated with severe nausea, but no vomitting. Denies recent fevers or illnesses, cp/sob, diarrhea, change in appetite, urinary symptoms. Last BM yesterday morning. No bloody or dark stools. Reports 2 prior episodes of same pain, 3wks ago and 6months ago. Similar in nature, waking him from sleep, but resolved with NSAIDs. Pain episodes are not associated with food. Radiology showed 1. Distended gallbladder with positive sonographic ___ sign, but no definite stones, wall edema, or pericholecystic fluid. Findings were equivocal for acute cholecystitis. HIDA scan may be obtained for further evaluation. 2. Hepatic steatosis. More severe forms of liver disease, including cirrhosis, cannot be excluded. The patient was diagnosed with ABDOMINAL PAIN RUQ, ASYMPTOMATIC HIV INFECTION. The patient was treated with HIDA scan. At the time of discharge, the patient had Primary: abdominal pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo M with HIV presenting with acute onset severe RUQ abdominal pain radiating to the epigastric region initially concerning for cholecystitis but more likely gastritis, after having normal labs and negative HIDA scan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old gentleman with history of CAD s/p 4 vessel CABG, dyslipidemia and ?diverticulosis who presented to the ___ dark stools x 2 days and lightheadedness x ___ days. He reported that he initially believed that his dark stools were due to changes in diet (eating brownies). Associated symptoms included appearing pale to his co-workers. This morning he felt dizzy when he woke up and then had a completely black bowel movement. No BRBPR, hematochezia or maroon colored stools. No recent consumption of iron supplements or pepto bismol, however he has taken a full dose aspirin for many years. He went to work as a ___ and felt persisent lightheadness so he called his supervisor and was given a ride to the ED. He presented to the ___ ED where his initial vitals were 97.8 78 141/78 18 100% RA. His hematocrit was 32.3 from a baseline of ~40 (in ___. He stools in the ED were noted to be melanotic and guaiac positive. He was seen by GI who were concerned about a possible upper EGD. GI recommending starting the patient on PPI bolus and PPI gtt. 2 peripheral IVs were placed prior to transfer to Medicine floor. On the floor, he reports some ongoing lightheadness with ambulation. He reports that his last bowel movement was this morning. He continues to deny BRBPR and hematochezia. The patient has no history of upper or lower GIB. He has a questionable h/o diverticulosis -- he reports that he was never told he has diverticulosis by a MD, but believes he may have this because he has a lot of pain with peanut ingestion. Radiology showed No acute cardiopulmonary process. Radiology showed No evidence of deep venous thrombosis. The patient was diagnosed with GASTROINTEST HEMORR NOS, AORTOCORONARY BYPASS. The patient was treated with ___ EGD ___ EGD. At the time of discharge, the patient had Upper gastrointestinal bleed. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old gentleman with h/o CAD and diverticulosis who presented with dark stools and drop in hematocrit concering for a upper GI bleed. # Upper GI bleed: At admission the patient reported dark stools, associated with dizzyness. He Hct in the ED was 32 from a baseline of Hct ~40. His stools in the ED were noted to be melanotic and guaiac positive. He was seen by GI who were concerned about a possible upper GI bleed. He was started on a PPI gtt and home beta blocker and diltiazem were held. On the floor his hematocrit was trending down 32 -> 29 -> 27 so the patient was transfused 1 unit overnight on ___ . His hematocrit increased to 29 after the transfusion. GI performed an EGD on ___ which was notable for erythema and petechiae in the antrum compatible with gastritis, granularity and erythema in the duodenal bulb compatible with duodenitis, and blood was seen in the duodenum -- however there did not appear to be any sites of active bleeding. He was transitioned to PO BID high dose PPI. He was dizzy with ambulation and noted to have a hematocrit of 26 on ___ so he was transfused 2 units. Post transfusion hematocrit was 31. GI repeated EGD on ___, which again did not identify a source of active bleeding. Serial hematocrits were checked and were noted to be stable (___) in the day prior to discharge and on the day of discharge. The patient will f/u with PCP to have another CBC checked in the coming days. Patient will be seen by ___. # Right shoulder pain, likely muscle sprain: The patient developed new right shoulder pain overnight on ___. His exam was not concerning for a septic joint or acute monoarticular process. He denied any trauma. His shoulder pain did not radiate or appear to be neuropathic. Shoulder x-ray was negative for acute process. Pain improved with tylenol. The patient also reported some mild lower extremity pain on the day of discharge. He was able to ambulate and was not significantly limited by the pain. ___ was negative for DVT. # CAD s/p CABG ___: Continued home dose of statin. Full dose aspirin was changed to 81mg aspirin given risk for bleeding. Initially held beta blocker and diltiazem in setting of acute bleed -- these medications were restarted prior to discharge. # Hypercholesterolemia: Continued home dose of statin.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PRIMARY CARE PHYSICIAN: ___ Radiology showed 1. Severe right hydroureteronephrosis with 3 stones in the right distal ureter, largest measuring 1.1 cm. 2. New non-obstructive 5-mm left renal calculus. Radiology showed Severe right sided hydronephrosis. Successful placement of an 8 ___ percutaneous right-sided nephrostomy tube. Radiology showed Right nephrostomy catheter left in situ given a small stone in the lower calyx and no passage of contrast beyond the mid ureter. The tube was capped. Findings and recommendations discussed between Dr. ___ Dr. ___ at the time of the exam on ___. The patient was diagnosed with CALCULUS OF KIDNEY. The patient was treated with ___: Placement of an 8 ___ percutaneous right-sided nephrostomy tube. ___: Right ureteroscopy with laser lithotripsy, and placement of double-J stent, and basket extraction of stone. ___: Right nephrostomy catheter left in situ given a small stone in the lower calyx and no passage of contrast beyond the mid ureter. The tube was capped.. At the time of discharge, the patient had ___: SEVERE RIGHT HYDRONEPHROSIS PREOPERATIVE DIAGNOSIS: Right multiple ureteral stones and right renal calculus, history possible urosepsis. POSTOPERATIVE DIAGNOSIS: Right multiple ureteral stones and right renal calculus, history possible urosepsis.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Hospital course prior to transfer to urology service: ___ w/ h/o obstructive nephrolithiasis presents with right flank pain and fevers, found to have severe hydronephrosis ___ large ureteral stone, now s/p percutaneous nephrostomy. # Pyelonephritis / Obstructive nephrolithiasis: Patient's presentation with right flank pain, fevers, and pyuria is consistent with pyelonephritis. Evidence of severe obstructive nephrolithiasis qualifies this as complicated pyelonephritis. She received right percutaneous nephrostomy, spiked fever to 105.5 shortly after her procedure, likely representing an episode of transient bacteremia. Treated complicated pyelonephritis with IV ampicillin/sulbactam. She was admitted to the MICU for monitoring given her fever and tachycardia. Remained hemodynamically stable although with mild orthostasis by heart rate. Overnight febrile to 101. Pain at nephrostomy site treated with oxycodone. She was sent to the floors where she remained febrile and was started on ceftriaxone. # ___: Patient presents with an elevated creatinine of 1.4 (bl of 1.0). This may be related to her obstructive nephrolithiasis, though this is unlikely because the obstruction is unilateral. A more likely explanation is pre-renal azotemia in combination with recent NSAID use. She received 4L NS in the ED, a further 1L NS in the MICU given asymptomatic orthostasis. Her creatinine returned to normal. # Postpartum: The patient was one week post-partum, recovering well with scant vaginal bleeding. She was pumping breast milk, advised to discard after antibiotic administration. # Glucose management: check daily FSGs # FEN: regular diet, IVF as above, replete electrolytes # Prophylaxis: - DVT: heparin SC - GI: none required # Access: 2 PIVs # Restraints: not needed # Communication: Patient # Code: Full # Disposition: ICU pending clinical improvement Ms. ___ was transferred to the general urology service on ___ morning, ___, where she remained until discharge. She was prepped for operative intervention and taken to the OR on ___ where she underwent right ureteroscopy with laser lithotripsy, and placement of double-J stent, and basket extraction of stone. She tolerated the procedure well; see dictated note for full details. The right percutaneous nephrostomy was open to gravity drainage until she arrived back on the general surgical floor when it was capped. On POD1 she was takne to the ___ suite where they attempted PCN removal but because of a stone/blockage, this was terminated and she was sent back to the general surgical floor. She was voiding independently and pain was well controlled. She was therefore set up with visiting nurse services to facilitate care of the PCN and her transition home. She will follow up with Dr. ___ definitive management in the next ___ days. She was given a course of Keflex and additional pain medications with instructions to check in with her pediatrician and OBGYN clinicians. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH of multiple sclerosis is presenting with BRBPR. 1 day prior to admission patient passed a normal bowel movement followed by large amount of bright red blood with clots. During this time she had severe abdominal pain. She continued to have BMs that were mostly blood and clots so she came to the ED. The BRBPR started suddenly, she rates it as severe, it is not getting better, it has been going on for 1 day. CT ABD AND PELVIS WITH CONTRAST showed Colitis involving the entire descending colon from the splenic flexure to its junction with the sigmoid colon, either infectious or inflammatory in etiology with ischemia not excluded. No evidence of pneumatosis, free intraperitoneal air, or drainable fluid collection. The patient was diagnosed with Hemorrhage of anus and rectum. At the time of discharge, the patient had Colitis Multiple sclerosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ is a ___ with PMH of multiple sclerosis who presented to the ED with BRBPR and was found to have colitis, thought to be most likely infectious in etiology. Patient presented initially with 1 day of BRBPR. She reportedly passed a normal stool which was then followed by a large amount of red blood and clots and subsequent frequent bleeding. In the ED she was found to be hemodynamically stable, with stable Hgb, and CT consistent with colitis of the entire descending colon from the splenic flexure to the junction of the sigmoid colon. She had mild leukocytosis, normal lactate and CRP 42. Cdiff, Ecoli O157, Shigella, Campylobacter all negative. She improved with ceftriaxone and flagyl, had no further bleeding, and was switched to ciprofloxacin (trialed off flagyl and monitored overnight as she reported intolerance of the medication with severe nausea) with plan for a 7d course. She was afebrile during her hospitalization. Patient reported a history of a very similar episode in the past during a trip to ___, the etiology of which was never discovered which reportedly also involved the left colon. In discussion with GI, she was set up with close outpatient GI follow-up with Dr. ___ at ___ for re-evaluation and consideration of outpatient colonoscopy. With regards to her MS, her copaxone was held initially in the setting of her infection, but was restarted after patient improved clinically. Patient's Neurologist Dr. ___ was notified of admission per patient's request and agreed current symptoms are unrelated to her MS. ___, spironolactone was held in house but restarted on discharge due to improved po intake.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with the past medical of cholelithiasis s/p CCY who presents with abdominal pain. Patient notes onset of severe, cramping and pressure-like abdominal pain starting ___. Pain was associated with food, sometimes relieved with belching and defecation. Pain was ___, no associated n/v, diarrhea. Patient does endorse chills. She tried tums and Prilosec for the pain however this did not help. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Intrahepatic and extrahepatic biliary ductal dilation with CBD measuring 12 mm. Findings are concerning for distal CBD obstruction and ERCP is recommended to further assess. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with ERCP with sphincterotomy. At the time of discharge, the patient had Elevated liver enzymes Abdominal pain Dilated common bile duct. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female with the past medical of cholelithiasis s/p CCY who presents with abdominal pain. #Abdominal pain #elevated LFTs #dilated CBD concerning for choledocolithiasis #s/p ERCP - initially there was concern for choledocolithiasis given constellation of findings included elevated LFTs and dilated CBD however patient underwent ERCP with no stones visualized, sludge removed. Patient was placed on ciprofloxacin after the procedure per ERCP recs. Patient will be on cipro for 5 days total. She was maintained on IVF overnight. Patient denied further abdominal pain the following day and tolerated a regular diet. LFTs improved. She was discharged home in stable condition. Transitional issues -LFTs down-trending on day of discharge although not full normalized, will need repeat labs with PCP ___ than 30 minutes were spent coordinating and providing care for this patient on day of discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH notable for A fib on coumadin, intermittend hematuria for years presenting with lightheadedness and dyspnea on exertion for three days. Patient has had intermittent hematuria for ___ years with known cystoprostatic bleeding and bladder calculi. Of note he was recently diagnosed with E. coli UTI last week (culture from ___, completed 3-day course of a quinolone this morning. Still intermittent hematuria and rust-colored urine, passing some clots in ED. Denies chest pain/pressure, orthopnea, extremity swelling, fevers/chills, back pain, syncope or presyncope, vertigo, HA, or visual changes. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. The patient was diagnosed with ANEMIA NOS, HEMATURIA, UNSPECIFIED, CARDIAC PACEMAKER STATUS, LONG TERM USE ANTIGOAGULANT. At the time of discharge, the patient had Primary: chronic iron deficiency anemia, hematuria. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Admitted with iron deficiency anemia. No evidence of GI losses so this may be due to chronic urinary blood loss. He was transfused one unit and improved symptomatically with this, but will need further urological work up and potentially colonoscopy as oupatient. Physical therapy evaluated patient and recommended ___ rehabilitation, however, patient was not agreeable and wished to go home with rehabilitative services. He was discharged in stable condition to outpatient follow-up with his outpatient providers. Discharged on percocet for 7 days(Q8H) for jaw pain, likely TMJ. #. Dyspnea on exertion: Pt. c/o dyspnea on exertion. CXR with no acute cardiopulmonary process to suggest pneumonia. Also no pulmonary edema on CXR, BNP elevated similar to prior value. PE unlikely in setting of normal oxygen saturation and another explanation. Etiology most likely anemia due to urinary blood loss. Repeat H+H stable and symptoms resolved post-transfusion. Pt worked with patient and recommended rehabiliation but patient deferred in preference of home with services. He will follow-up continued resolution of symptoms with his PCP as outpatient. #. Anemia: Normochromic normocytic anemia. Differential includes anemia of chronic disease or multifactorial anemia (mixed microcytic and macrocytic) given that patient has been macrocytic in the past. Guaic negative in the ED and on repeat on floor. Given normocytic anemia with low ___ represent mixed dx given history of macrocytosis. Maintained active type and screen. Monitored for s/s bleeding. Held on CBI given continud voiding. Urologicy plan per below. #. Hematuria: Intermittent for many years. Outpatient urologist called how did not recommend CBI unless stops urinating and inpatient urology consult. Hematuria had grossly resolved on hospital day #2. After discussion with outpatient urologist, Dr. ___, decided to defer further evaluation to outpatient setting given stability of symptoms. Will likely undergo cystoscopy with Dr. ___. # UTI UA floridly positive but difficult to interpret given hematuria. No leukocytosis, fever, dysuria. UCx grew yeast. # Jaw discomfort New onset, mild, day of admission. No sign of local infection (no erythema, LAD, leukocytosis). Has not tried pain reliever. Trop negative x1. Sx improved with acetaminophen. Improved hospital day #2. Patient prescribed percocet and will follow-up with his PCP as outpatient for further work-up.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with a history of alcohol abuse presenting today for evaluation of an upper GI bleed. He was brought into the outside hospital today at request of his girlfriend as patient looked more lethargic than normal. He also had episodes of coffee-ground emesis earlier today. This was also witnessed while at the outside hospital. Lab tests there were notable for a bilirubin of 6 and platelets of 64. Patient was then transferred here for continuous evaluation of upper GI bleed. Recent sick contact at home with his girlfriend ___ daughter, and URI symptoms since ___ with new cough. On arrival states that he has relapsed into alcohol since last ___. Last drink this AM, drinks ~1 bottle vodka daily. Has no diagnosis of cirrhosis but has been told in the past that his lab tests looking at his liver have been concerning. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Probable cirrhosis with evidence of portal hypertension including hepatofugal portal venous flow and splenomegaly. Gallbladder wall edema is likely third spacing related to primary liver disease. CHEST (PORTABLE AP) showed Large area of right mid to lower lung opacity, concerning for consolidation, possibly due to pneumonia and/or aspiration. Right internal jugular central venous catheter terminates in the mid SVC without evidence of pneumothorax. Left costophrenic angle not well seen, may be due to overlying soft tissue, but a pleural effusion is not excluded. The patient was diagnosed with Sepsis, unspecified organism, Granuloma faciale [eosinophilic granuloma of skin], Hypotension, unspecified, Pneumonia, unspecified organism, Alcohol dependence with withdrawal, unspecified, Acute and subacute hepatic failure without coma. The patient was treated with ___: Upper endoscopy. At the time of discharge, the patient had Primary diagnosis: Septic shock Pneumonia Secondary diagnoses: Obstructive sleep apnea Upper GI bleed Macrocytic anemia Alcoholic hepatitis Alcohol use disorder Coagulopathy Cirrhosis Thrombocytopenia Anisocoria. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with alcohol abuse who presented with upper GI bleed and concern for septic shock. # Septic shock secondary to pneumonia: Patient presented with cough, leukocytosis, and CXR with consolidation concerning for pneumonia. No ascites for spontaneous bacterial peritonitis and hemoglobin relatively stable so unlikely blood loss. There was some initial concern for blood loss contributing to his shock, but his hemoglobin remained stable. He briefly required pressor support and was given volume resusictation for hypotension. He was treated with ceftriaxone and azithromycin for a total of 5 days. # Upper GI bleed: Patient had episodes of coffee ground emesis before presentation. His stool was noted to be brown on exam. Upper endoscopy performed on ___ showed evidence of portal hypertensive gastropathy but no varices. He was briefly treated with IV PPI and octreotide drip and later transitioned to PO PPI. # EtOH use disorder: Patient with significant drinking history at home, drinking up to 1 bottle of vodka per day. He was given a phenobarbital load and taper. He was also started on high-dose thiamine, folate, and multivitamin. Social work was consulted. # Nighttime desaturations: # OSA: Patient with nighttime desaturationa. Given body habitus and nighttime occurrences, most likely sleep apnea, but it has never been diagnosed formally. Sleep medicine consulted and recommended empiric CPAP while inpatient. Given persistent hypoxia (especially with ambulation), patient underwent ECHO with bubble study that showed moderately increased PASP with no evidence of right to left shunt. Given persistent hypoxia, patient discharged on home oxygen with plan for outpatient sleep study. Until he has CPAP at home, he should wear 4 LPM of O2 at night. He can also use supplemental oxygen if desaturating with ambulation activity; this can be titrated and weaned by a visiting nurse. # Alcohol hepatitis: Patient presented with elevated t.bili and coagulopathy with ___ Discriminant Function of 34 on admission, concerning for alcoholic hepatitis. He was not given steroids in the setting of active infection. Total bilirubin downtrended throughout admission. # Coagulopathy: INR elevation likely due to cirrhosis and poor nutrition. His labs were monitored daily without need for vitamin K. # Cirrhosis: No formal diagnosis but evidence of cirrhosis on RUQUS with splenomegaly, mild jaundice, and consistent history of alcoholic cirrhosis. MELD-Na 20. AST>ALT 2:1 so likely alcoholic. Workup for other causes of cirrhosis including elevated IgG, IgA as well as normal IgM. ___, AMSA, AMA, tTGA anti-tissue transglutaminase pending at time of discharge. Right upper quadrant ultrasound showed evidence of portal hypertension including hepatofugal portal venous flow and splenomegaly. Upper endoscopy on admission without varices but with portal hypertensive gastropathy. He will need outpatient Hepatology follow up with ___ screening and varices screening. # Thrombocytopenia: Most likely due to underlying liver disease. Blood smear without shistocytes and hemodynamically stable so DIC/TTP unlikely. Low fibrinogen likely in the setting of liver disease. Subcutaneous heparin was held given his low platelets but restarted once platelets were over 50. # anisocoria: Patient with dilated left pupil>right but no diplopia, eye pain, or other neuro symptoms. Left pupil sluggish to react. Rest of neurologic exam unremarkable so less concern for aneurysm/intracranial process. Patient was on ipatroprium which can cause anisocoria so it was discontinued with resolution of anisocoria. =====================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ history of chronic pneumobilia of unclear etiology, seizure disorder, GERD, gout, presenting with worsening abdominal pain to ___, found to be febrile with CT A/P showing pneumobilia with cholelithiaisis, RUQUS without definitive evidence of cholecystitis transferred here for ERCP evaluation. CHEST (PA AND LAT) PORT showed No acute intrathoracic abnormality. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Sonographic findings are equivocal for acute cholecystitis. The gallbladder is only partially distended and filled with sludge and air however with minimal wall thickening without a positive sonographic ___ sign or pericholecystic fluid. Further evaluation with HIDA scan may be performed if clinically indicated. 2. Pneumobilia as seen on recent outside hospital CT abdomen pelvis. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 6:58 am, 5 minutes after discovery of the findings. CHEST (PORTABLE AP) showed 1. Interval placement of a right central venous catheter line which projects over the low SVC. 2. No complications. SECOND OPINION CT TORSO showed 1. There is no evidence of a perforated duodenal diverticulum. Distortion and hyperenhancement of the wall of a short segment of the duodenum in its second portion in the periampullary region is likely related to chronic ulcer disease or recent passage of sludge/gallstones, especially given the presence of unexplained pneumobilia. 2. Air within the gallbladder and pneumobilia noted. The CBD also demonstrates presence of air within it, however tapers normally towards the ampulla without visualization of an obstructing mass or calculus at the ampulla. 3. No other acute process seen in the abdomen or pelvis to explain patient's symptoms. RECOMMENDATION(S): Additional evaluation for cause of pneumobilia and evaluation of the second portion of the duodenum by ERCP is recommended. CT ABD AND PELVIS WITH CONTRAST showed 1. Pneumobilia, extrahepatic biliary dilatation and oral contrast filling the CBD in a retrograde fashion suggests sphincter of Oddi dysfunction/incompetence, possibly due to recently passed gallstone. 2. No evidence of bowel perforation. No free intraperitoneal air. CHEST (PORTABLE AP) showed Compared to chest radiographs ___. New ring shadows in the right mid and lower lung zone are due to bronchial wall thickening or extra bronchial cuffing. Differential diagnosis includes early edema or new widespread bronchial inflammation. There are no findings of edema elsewhere or any consolidation in the lungs. Heart size top-normal. No appreciable pleural effusion or pneumothorax. Right jugular line ends in the low SVC, as before. Ultrasound-guided percutaneous cholecystostomy tube placement. showed Successful US-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. CHEST (PA AND LAT) showed Interval removal of right internal jugular central venous catheter with no evidence of pneumothorax. No evidence of pneumonia or pleural effusion. Pigtail catheter projects over the right upper abdomen. GI fluoroscopy showed Cholecystostomy tube is in satisfactory position. MRCP showed 1. No evidence of a bile leak or biloma. 2. Pneumobilia, without evidence choledocholithiasis. 3. 3.0 x 2.1 cm ill-defined focus of heterogeneous T2 hyperintense signal intensity in the gallbladder fossa with inflammation of the surrounding hepatic parenchyma, likely containing some fluid which may be postsurgical. Superimposed infection/phlegmon cannot be excluded, but there is no drainable collection. 4. Trace right pleural effusion. The patient was diagnosed with Sepsis, unspecified organism, Acidosis, Unspecified abdominal pain. The patient was treated with ___ ___ placed Percutaneous Cholecystostomy ___ Laparoscopic cholecystectomy. At the time of discharge, the patient had PRIMARY DIAGNOSES: ================== -Septic Shock -E. Coli Bacteremia -Cholecystitis s/p percutaneous cholecystostomy s/p laparoscopic cholecystectomy SECONDARY DIAGNOSES: ==================== -Chronic Pneumobilia -Herpes re-activation -Gout -GERD -Seizure disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ history of chronic pneumobilia thought to be secondary to sphincter of Oddi incompetence, seizure disorder, GERD, gout, who initially presented with worsening abdominal pain to ___, found to have pneumobilia transferred here for consideration of ERCP. Underwent HIDA found to have acute cholecystitis with E. Coli bacteremia. Underwent percutaneous cholecystostomy and narrowed to ciprofloxacin and flagyl. Then underwent laparoscopic cholecystectomy. ACUTE ISSUES ==================== #E. Coli bacteremia #Cholecystitis s/p percutaneous cholecystostomy s/p laparoscopic cholecystectomy #Septic Shock Patient initially presented with acute on subacute worsening abdominal pain, fevers, chills to ___. There with normal LFTs, however on CT A/P WO contrast found to have pneumobilia, cholelithiaisis, with RUQ U/S equivocal for cholecystitis. Given pneumobilia was transferred to ___ for consideration of ERCP. Found to have septic shock with E. coli bacteremia requiring pressors. Ultimately underwent HIDA confirming acute cholecystitis. In consultation with both ACS and ___, underwent percutaneous cholecystostomy. Was initially started on vancomycin for enterococcus coverage, cefepime, flagyl however narrowed to IV cipro based on sensitivities. Was weaned off of vasoactive support prior to transfer to floor. Transitioned to oral cipro, but given continued abd pain and borderline fevers, flagyl was added back on ___. Patient underwent uncomplicated laparoscopic cholecystectomy on ___. Patient had significant pain secondary to the drain and the procedure, and was controlled with oxycodone and lidocaine patch. #Pneumobilia With chronic pneumobilia for which patient underwent ERCP in ___ for work-up of pneumobilia. Showed duodenal ulceration however without evidence of enteric-biliary fistula. Also found to have duodenal stenosis on ERCP in ___ for which was unable to pass duodenoscope past stricture. Given known stricture, per ERCP during this admission deferred ERCP given would be unlikely to pass scope past the stricture. Underwent CT A/P WC which ruled out duodenal diverticulum perforation as cause of his pnuemobilia. Found to have contrast reflux into CBD suggestive of sphincter of oddi dysfunction/incompetence which is likely the cause of patient's known chronic pneumobilia. #Herpes re-activation Post percutaneous cholecystostomy, had oral HSV re-activation. Was treated with five day course of Valtrex. CHRONIC ISSUES ==================== #Gout Continued home allopurinol ___ PO QD #GERD Continued home omeprazole 20mg PO QD #Seizure disorder Continued home phenobarbital 64.8mg PO BID TRANSITIONAL ISSUES =================== [ ] Patient evaluated by occupational therapy as inpatient, complete MOCA evaluation with score of ___ suggestive of cognitive impairment. Arranged for neurocognitive follow up as outpatient This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with T3N0M0 poorly differentiated squamous cell carcinoma of the esophagus s/p neoadjuvant chemoradiation therapy followed by minimally invasive esophagectomy with Dr. ___ ___, now with local recurrence/lymph node metastasis undergoing salvage chemoradiation therapy. She underwent a laparoscopic feeding jejunostomy tube placement on ___ with Dr. ___. She tolerated this without complications and went home the same day. She used her J-tube for feeding with no issues last night; she has been cycling her tube feeds. When she showered this morning, she dressed the J-tube site as usual, but noticed that the tube may have appeared loose although all the sutures were in place. She then noted when she tried to flush the tube later on, the water came out through the J-tube site. She then called into the office and was sent to the ED. Of note, she has noticed increasing irritation/redness around the J-tube site, as well as surrounding the sutures. She has not had any temperatures at home, but has felt some chills. She continues with chemoRT and has been tolerating that well with some nausea. She is still able to eat soft foods with careful chewing as she does have some dysphagia, and as previously mentioned, cycles her tube feeds at night. She moves her bowel regularly with the help of miralax. She is scheduled for her next radiation treatment this morning at 8:45AM on ___. G/GJ/GI TUBE CHECK showed Appropriately placed jejunal tube. The patient was diagnosed with Enterostomy infection, Cellulitis of abdominal wall, Form of external stoma cause abn react/compl, w/o misadvnt. The patient was treated with ___ Jejunostomy tube replacement. At the time of discharge, the patient had Wound cellulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ was evaluated by the Thoracic surgery service in the Emergency Room and admitted to the hospital for obcervation of her abdominal cellulitis. She remained afebrile and had a normal WBC. An attempt was made to drain an area adjacent to the J tube but the entire area was hard and erythematous. There was no fluctuant area. The J tube was replaced with an ___ Fr tube and placement was confirmed by xray. The tube was taped securely to an area that had no skin breakdown. Bactrim was started and the plan is for her to continue a 10 day course of oral Bacrtim. She will be seen tomorrow by Dr. ___ to assess the area and potentially suture the tube in place tomorrow in the Thoracic Clinic. She was discharged on ___ prior to her radiation appointment.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Mr. ___ is a ___, former smoker, with PVD s/p aortobifemoral bypass (___ ___ vs ___ per wife), who presented to the OSH with sudden onset abdominal pain this morning. He underwent a CTA which showed a disrupted proximal anastomosis of the aorto-femoral graft with rupture. Additionally he has a right groin pseudoaneurysm between the right limb of the aort-bifemoral graft with the native artery which appears contained. He was therefore transferred to ___ for further management. On Medflight, he became hypotensive with worsening abdominal distention and was given a total of 4u pRBC and ___ FFP. He was taken directly to the OR for definitive treatment. CHEST (PORTABLE AP) showed Comparison to ___. The monitoring and support devices are stable. Moderate cardiomegaly persists. Minimal bilateral pleural effusions. Signs of mild pulmonary edema. No new focal parenchymal changes. CHEST (PORTABLE AP) showed The support lines and tubes are in stable position. Low lung volumes are noted. Small bilateral pleural effusions and bibasilar opacities are unchanged. There is no overt pulmonary edema. The cardiomediastinal silhouette is stable in appearance. No acute osseous abnormalities are identified. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___ through ___. Left lower lobe collapse unchanged. Mild pulmonary edema more pronounced in the right lung, moderate right pleural effusion is small left pleural effusion unchanged. No pneumothorax. Heart size normal. Cardiopulmonary support devices in standard placements. CHEST (PORTABLE AP) showed Low lung volumes bilaterally, with increased vascular congestion. Moderate pleural effusion on the right and small pleural effusion on the left. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___ through ___. Patient is rotated to his left, obscuring the left lower lobe which is probably still collapsed. Basal atelectasis is also persistent in the right lower lobe, severity indeterminate. The right upper lobe is clear. The heart is not enlarged. There is no pneumothorax. ET tube in standard placement. Transesophageal drainage tube passes into the stomach and out of view. Left jugular line ends in the low SVC. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___ through ___. There is no longer pulmonary edema. Severe left lower lobe atelectasis and small pleural effusions persist. Heart size top-normal. No pneumothorax. Cardiopulmonary support devices in standard placements. CHEST (PORTABLE AP) showed In comparison with the study of ___, there again are low lung volumes. Monitoring and support devices are stable. Cardiac silhouette is enlarged and there is increased engorgement of ill defined pulmonary vessels consistent with elevated pulmonary venous pressure. Bilateral pleural effusions with compressive atelectasis is seen. CHEST PORT. LINE PLACEMENT showed In comparison with the study of 6 hours previously, there has been placement of a left IJ catheter that extends to the lower SVC. No evidence of post procedure pneumothorax. Cardiomediastinal silhouette is less prominent and there is substantial decrease in the bilateral pulmonary opacifications that most likely represented pulmonary edema. There again are bilateral pleural effusions with compressive basilar atelectasis, more prominent on the right. UNILAT UP EXT VEINS US LEFT showed No evidence of deep vein thrombosis in the left upper extremity. CHEST (PORTABLE AP) showed Lungs are low volume with small bilateral effusions right greater than left. Cardiomediastinal silhouette is stable. There is mild pulmonary vascular congestion. The ETT, NG tube and left-sided central line are unchanged. No pneumothorax. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___ through ___. Pulmonary vascular congestion persists. Large area of consolidation right lower lobe in smaller regions of peribronchial opacification suggest widespread pneumonia. Heart size normal. Small pleural effusions are likely. No pneumothorax. Cardiopulmonary support devices in standard placements. CTA TORSO showed 1. Interval repair of a ruptured infrarenal abdominal aortic aneurysm with aortobifemoral graft placement. 2. Expected interval evolution of the large hematoma in the right hemiabdomen, which appears to be involuting and measures up to 17.0 cm. No evidence of active extravasation identified. 3. Stable right common femoral pseudoaneurysm measuring approximately 2.2 x 1.8 cm. 4. Unchanged appearance of a chronic bilobed fluid collection in the left inguinal region, measuring up to 6.8 cm. 5. Nonspecific 1.9 cm left adrenal nodule, indeterminately characterized but most commonly adenoma. A dedicated CT/MRI with adrenal protocol on a nonemergent basis as an outpatient may be performed if needed for better characterization. 6. Focal ground-glass opacities in the right upper lung, possibly representing infection or asymmetric edema. 7. Persistent small left pleural effusion and new small right pleural effusion, with adjacent compressive atelectasis. 8. Mildly enlarged right hilar lymph node measuring 13 mm, presumably reactive. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are unchanged and in satisfactory position. Improved, though still relatively low lung volumes. Cardiomediastinal silhouette is stable and there is indistinctness of engorged pulmonary vessels consistent with the clinical concern for volume overload. Opacification at the left base silhouetting hemidiaphragm is consistent with pleural fluid and volume loss in left lower lobe. Band of atelectasis at the right base is now seen instead of the more amorphous opacification previously noted. Nevertheless, the possibility of superimposed pneumonia would have to be considered in the appropriate clinical setting. CHEST (PORTABLE AP) showed Right atelectatic band in left lower lobe collapse are unchanged. However, in the appropriate clinical setting, it would be difficult to exclude superimposed consolidation. CHEST (PORTABLE AP) showed Right atelectatic band and left lower lobe collapse are unchanged. However, in the appropriate clinical setting, it would be difficult to exclude superimposed consolidation. CHEST PORT. LINE PLACEMENT showed No comparison. The patient is intubated. The tip of the endotracheal tube projects approximately 3 cm above the carinal. The course of the feeding tube is normal. Right internal jugular vein catheter, left internal jugular vein catheter, both in correct position. Lung volumes are low. There is mild cardiomegaly and mild to moderate pulmonary edema, combines to a small left pleural effusion as well as a relatively extensive right basilar atelectasis. No pneumothorax. CHEST (PORTABLE AP) showed 1. No evidence of pneumothorax. 2. Improved pulmonary vascular congestion. 3. Possible aspiration/pneumonia in the right lower lung in the correct clinical setting. CHEST (PORTABLE AP) showed Patient is rotated to the right. The left IJ line projects at the junction of the left brachiocephalic and SVC. The NG tubes are unchanged. Lungs are low volume with patchy parenchymal opacity in the right lower lobe and left lower lobe, unchanged. Small bilateral effusions left greater than right are unchanged. No pneumothorax. Mild pulmonary vascular congestion. Radiographs with limited views of chest and abdomen. showed 1. Dobhoff tube successfully placed in the stomach. 2. Central line terminates in the azygos vein. 3. Interval resolution of right-sided basilar lung opacities, persistence of left-sided basilar opacities and pleural effusion. NOTIFICATION: Findings communicated to ___, MD by ___ ___, MD at 16:33 on ___ 20 minutes after discovery of the findings. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are stable. Continued low lung volumes with enlargement of the cardiac silhouette and elevation of pulmonary venous pressure. Retrocardiac opacification with obscuration of the hemidiaphragm is consistent with volume loss in left lower lobe and pleural effusion. The opacification at the right base has substantially decreased. CHEST (PORTABLE AP) showed In comparison with the study of ___, the patient has taken a much better inspiration. The tip of the endotracheal tube is approximately 5 cm above the carina. Other monitoring and support devices are stable. Continued relatively low lung volumes with enlargement of the cardiac silhouette and moderate pulmonary edema. Opacification in the retrocardiac region with obscuration hemidiaphragm is again consistent with volume loss in left lower lobe and pleural effusion. There is an area of increased opacification above the right hemidiaphragmatic contour. This most likely represents merely atelectatic changes. However, in the appropriate clinical setting, superimposed aspiration/pneumonia would have to be considered. CT HEAD W/O CONTRAST Q111 CT HEAD. showed 1. No evidence of acute intracranial abnormality or hemorrhage. 2. Chronic right caudate nucleus infarct, and chronic posterior right parietal lobe infarct as described above. 3. Moderate paranasal sinus disease with complete opacification of the bilateral mastoid air cells and layering fluid within the bilateral sphenoid sinuses and maxillary sinuses, possibly sequela of intubation. BILAT UP EXT VEINS US showed Nonocclusive venous thrombosis in the right internal jugular vein. Remainder of the right upper extremity veins and left extremity veins are without thrombus. GO TO NOTIFICATION CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___ through ___. Although lung volumes are still relatively low, previous left lower lobe atelectasis has improved substantially. Pulmonary edema is mild. Mild cardiomegaly has improved since ___. Small left pleural effusion unchanged. No pneumothorax. No endotracheal tube is seen. Transesophageal drainage tube ends at the thoracic inlet either in the airway or upper esophagus. Transesophageal feeding tube ends in the proximal duodenum. Left jugular line tip in the low SVC. NOTIFICATION: The findings were discussed with ___, RN, by ___, M.D. on the telephone at 12:49, IMMEDIATELY following discovery of the findings. CHEST (PORTABLE AP) showed In comparison with the study of ___, there are slightly improved lung volumes. The endotracheal tube is been removed. What appears to of been a transesophageal drainage tube has been removed. The other monitoring and support devices appear stable. Cardiomediastinal silhouette is unchanged. Mild engorgement of ill defined pulmonary vessels is consistent with elevated pulmonary venous pressure. Basilar opacification on the left is consistent with pleural fluid and atelectatic changes. Radiology showed There has been improvement of the pulmonary edema. The left IJ central line has been removed. There is a feeding tube with distal tip is below the edge of the film, past the GE junction.. There remains bibasilar opacities at the lung bases, left greater than right. There are no pneumothoraces. CHEST (PORTABLE AP) showed Comparison to ___. Stable correct position of the monitoring and support devices. New small to moderate bilateral pleural effusions, with subsequent areas of basilar atelectasis, in addition to the pre-existing right perihilar and basal opacity and consolidation. There also is a new retrocardiac atelectasis. No pulmonary edema. No pneumothorax. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change in the monitoring and support devices. The cardiac silhouette is again mildly enlarged with elevated pulmonary venous pressure that appears less prominent than on the prior study. The layering pleural effusions with compressive basilar atelectasis also are less prominent, though much of this could merely reflect a more upright position of the patient. CHEST (PORTABLE AP) showed Comparison to ___. Stable monitoring and support devices. Minimal increase in extent of the moderate right and small left pleural effusion. Stable basal areas of atelectasis. On the current image, signs of mild pulmonary edema present. Mild cardiomegaly persists. No pneumothorax. CHEST (PORTABLE AP) showed ET tube tip is 6 cm above the carina. NG tube tip is in the stomach. Right internal jugular line tip is at the level of mid SVC. Heart size and mediastinum are stable. Bibasal consolidations and bilateral pleural effusions are unchanged. There is interval improvement in pulmonary edema with only pulmonary vascular congestion currently present. CHEST (PORTABLE AP) showed The nasogastric tube terminates in the body of the stomach. The remaining support lines and tubes are in stable position. No other significant interval change compared to study from earlier today. The patient was diagnosed with Abdominal aortic aneurysm, without rupture. The patient was treated with ___ INFRARENAL PROXIMAL AORTIC CUFF X 4, OPEN ABDOMEN FOR WASHOUT OF HEMATOMA ___ ABDOMINAL WASHOUT, LOA, ABTHERA PLACEMENT ___ ABDOMINAL WASHOUT, CLOSURE OF ABDOMEN. At the time of discharge, the patient had Abdominal Aortic Aneurysm Rupture Peripheral Vascular Disease Anemia secondary to rupture requiring transfusion Oliguria Pleural effusions with pulmonary edema requiring diuresis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ PVD s/p aortobifemoral bypass (___) who presented to the OSH with sudden onset of abdominal pain with CTA confirming p/w ruptured ___ anastomosis. He was transfused 4u rPBC 2uFFP in medflight with worsening hypotension. He was taken immediately to the OR where he underwent infrarenal ___ aortic cuff x4 w open abdomen (see op note for further details). He was transferred to the ICU in critical condition. He was started on fondaparinux prophylaxis due to his history of HIT. His respiratory status was tenuous and he frequently desatted and required increasing FiO2 while he remained intubated. Pulmonology was consulted and he was started on Lasix. During this initial post-op period his antibiotic coverage was adjusted as appropriate and he was started on tube feeds. He had a TTE that showed a PFO, but cardiology did not feel that any intervention was necessary at this time. He returned to the OR on POD4 for an abdominal washout, lysis of adhesions, and abthera placement. Following his second trip to the OR he had continued PRN Lasix requirements in the ICU. Two days following this he became febrile and his R IJ line had evidence of pus when it was removed, so a L IJ was placed. His fevers continued and he was taken back to the OR again for another washout and at this time his abdomen was closed. After this third trip to the OR he was persistently hypertensive and required nicardipine for BP control. In the following days the ICU team attempted to wean him from the vent but it was not well tolerated. He also went into Afib and was started on metoprolol. He continued to be febrile so a CTA of his torso was obtained, but it showed no obvious source of infection that would explain his fevers. On POD12 from his original operation he was extubated, but developed respiratory distress and needed to be reintubated. The following day he continued to be febrile so ID was consulted. The following day he went into Afib with RVR again and was started on a dilt drip. He had an echo for unexplained hypotension which didn't show a cardiac cause, but revealed a thrombus in his IJ. At this time he was also transitioned to bivalirudin for a short period before being restarted on fondaparinux. On POD16 from his original operation he was successfully extubated and his oxygen requirements were subsequently weaned down. His mental status then became one of his chief issues, as he would only occasionally follow commands and would not communicate in any meaningful manner. His fevers subsided and on POD18 he was transferred to the VICU. While on the floor in the VICU his blood pressure and mental status were his main issues. Vascular medicine provided assistance with his anti-hypertensive regimen, which needed to be adjusted multiple times for adequate control. Neurology was consulted for his altered mental status, which they attributed to delirium secondary to an extended ICU stay. Additionally, ACS was consulted for placement of a PEG tube as he would likely need long term feeding access due to his mental status. Ultimately, his family opted not to go through with the PEG so that they could avoid reintubation, so his feedings were continued with the Dobhoff. Neurology attributed his mental status to delirium related to his prolonged ICU stay, so delirium precautions were put in place. His mental status began to improve and he became more conversant and oriented as time progressed. Vascular medicine continued to be involved in his care and he was diuresed as necessary. On hospital day ___ he had a brief run of afib that was seen on telemetry, but had no further issues with afib afterwards. On hospital day ___ he was hemodynamically stable and his mental status continued to improve so he was determined to be fit for discharge. His discharge was ultimately delayed due to difficulties with finding rehab placement, but by hospital day 27 case management had found a rehab facility and he was transferred there with plans to follow up with vascular surgery clinic for re-imaging of his abdomen.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old man with lung ___ on chemo who presents to ED after transfer from ___. Pt had an unwitnessed syncopal episode at 2:30 a.m. Pt's wife states she heard a fall while he was walking to the bathroom and found him after he struck the left anterior aspect of his face on the floor, laying on his bilateral hands. He presented to ___ where he reported B/L hand numbness on radial aspect and pain and L foot numbness s/p fall. At ___ head was negative, and CT Cspine revealed no fracture but narrowing at C3-C5. EKG showed multifocal PVCs. MRI CERVICAL SPINE, THORACIC AND LUMBAR SPINES showed 1. No definite evidence of bony metastatic disease although marrow signal is heterogeneous. 2. Severe changes of cervical spondylosis are seen at C3-4 C5-6 and C6-7 extrinsic indentation and deformity of the spinal cord with subtle increased signal within the spinal cord at C5 and C6 levels indicating cord edema or myelomalacia. 3. Multilevel degenerative changes in the thoracic and lumbar region without spinal stenosis at these levels. No evidence of fracture. 4. Right upper lobe lung mass which can be further evaluated with chest CT. Radiology showed No acute fracture or dislocation in either hand or wrist. Duplex Doppler evaluation of the extracranial carotid arteries. TECHNIQUE: Grayscale, color and spectral Doppler were used to evaluate the extracranial carotid arteries. HISTORY: ___ male with history of lung cancer and syncope. Request is to evaluate for carotid atherosclerosis. FINDINGS: RIGHT SIDE: There is mild heterogenous plaque involving the right ICA. Peak systolic velocities in the proximal, mid and distal ICA are 68 cm/sec, 62 cm/sec and 54 cm/sec respectively. Peak systolic velocities in the right common and external carotid arteries are 67 cm/sec and 110 cm/sec respectively. Peak systolic antegrade velocities in the right vertebral artery of 62 cm/sec are recorded. This yields a right-sided internal to common carotid ratio of 1.0, predictive of less than 40% stenosis. LEFT SIDE: Again, there is mild heterogenous plaque involving the left internal carotid artery ostium. Peak systolic velocities in the left proximal, mid and distal ICA are 53 cm/sec, 60 cm/sec and 48 cm/sec. Left common and external carotid artery peak systolic velocities of 54 cm/sec and 101 cm/sec are recorded. Again, there is normal antegrade flow in the left vertebral artery with a peak systolic velocity of 79 cm/sec. This yields a left-sided internal to common carotid ratio of 1.1, again predictive of less than 40% stenosis. IMPRESSION: Mild heterogenous plaque bilaterally. Flow velocities are indicative of less than 40% stenosis. showed Mild heterogenous plaque bilaterally. Flow velocities are indicative of less than 40% stenosis. Radiology showed 1. No definite focal consolidation, however cannot exclude a small opacity in the posterior lung, which could be obscured by the pleural effusions. 2. Right upper lobe mass, partially imaged on recent MR and similar to recent prior radiographs but new since radiographs from ___. Further evaluation by CT is recommended. The patient was diagnosed with SYNCOPE AND COLLAPSE. The patient was treated with C3-6 Laminectomy, C3-7 Posterior Fusion, Autografts/Allografts/Instrumentation on ___ ___ ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man with h/o lung ___, currently on chemo, who is transferred from ___ after a syncopal event and subsequent paresthesias. His MRI revealed narrowing of C3-C5 with cord edema and compression, now s/p decompression surgery by ortho spine for ___. His delirium and post-syncope workup were managed and he was discharged to ___ rehabilitation. # Syncope: Patient had unwitnessed fall immediately prior to going to bathroom. The differential includes vasovagal syncope, carotid artery stenosis, orthostatic hypotension, arrhythmia, and structural heart disease. Echocardiogram and carotid ultraound did not reveal significant disease, orthostasis improved with IV fluids, and the patient had no further presyncopal episodes. Discharged to ___ rehab. # Cervical stenosis and paresthesias: Patient had multiple compression fractures status-post syncope with cervical cord compression. Orthopedic Spine surgery performed an operative decompression, he was maintained on C-spine collar. He had residual arm weakness and moderate to severe hand weakness. Patient was discharged to ___ rehab and outpatient orthopedic followup. # Urinary Retention: No spontaneous void in hospital and initial concern for urinary retention and so a Foley was placed. Patient had difficulty spontaneously voiding post-Foley being pulled. Unclear if purely delirium, spinal cord injury, or medication-related. Patient had intermittent straight catheterization, tamsulosin dosing was altered, and ultimately he was voiding spontaneously on the day of discharge without difficulty. # Lung ___: Was on weekly chemotherapy. He will follow-up with oncologist Dr. ___ ___. ___ ___. # Delirum: AM ___ noted disorientation to time and visual hallucinations. Remainder of neuro exam essentially unchanged, has not had BM in 3 days. Normal LFTs aside from albumin 2.6. Per wife ___, he does not have much to drink, maybe ___ drinks/week or 1 case of beer per month. Had 25 WBC and moderate leukocytes on UA. B12/TSH within normal limits. Ultimately, patient had bowel movements, void spontaneously, was maintained on delirium precautions, and his mental status improved. No antipsychotics were needed for agitation. # COPD: Currently presenting with rhonchi and wheezing on exam, requiring 3L of 02, though is not on 02 at home, though currently having difficulty bringing up sputum while in C-Collar. On spiriva at home and albuterol nebs Q4H PRN here. Denies increased cough or sputum production. Chest X-ray was negative. Patient given incentive spirometry ___/hour, counseled on smoking cessation, given oxygen therapy, and chest physiotherapy was performed to optimize pulmonary status. # Anemia: Labs notable for Hct drop from 34 on admission to 27 today. Hgb 10.8 to 9.2. No evidence of acute bleed in the ICU. ___ be secondary to post-operative losses combined with IVF. He is now s/p 2 units pRBC transfusion in the ICU. By the time of discharge, his H/H was improving, stool guaiac was negative, and pRBCs were never utilized. # Sinus tachycardia: Likely secondary to volume depletion, particularly in the setting of positive orthostatics this morning. Currently denying pain or pleurisy. He has been progressively more net negative in the ICU throughout the day with progressive increase in HR. Thus the most likely etiology is hypovolemia. Less likely secondary to PE, though he does have an 02 requirement now (see above). Patient was repleted with IV NS several liters and his heart rate improved. # Atrial fibrillation: Chronic stable issue in sinus during this hospital stay. Patient received no rhythm control and no rate control (sinus tachycardia felt to be physiologic). Maintained on home aspirin 81mg (held prior to surgery). # HLD: Chronic stable condition continued on home atorvastatin # T2DM: HbA1c 7% , needs repeat draw in 3 months. # Small Bilateral Pleural Effusions: Patient has no known metastatic disease. A CXR may be done to document resolution and should require further diagnostics/interventions if no resolution. # Code Status: Full Code confirmed. Emergency contact is wife ___ ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with lumbar spinal injury with marked b/l ___ weakness, multifactorial CKD stage IV (b/l Cr ~2.1-2.3), obstructive uropathy w/ chronic Foley, L ureteral stricture s/p L PCN, recent admission to ___ ___ for UTI (ESBL E.coli and Stenotrophomas, s/p treatment with Ceftaz/Bactrim) presenting with b/l flank tenderness. Radiology showed Successful exchange of a 8.5 ___ nephrostomy on the left. CT abdomen and pelvis without contrast showed 1. Percutaneous nephrostomy tube is seen in the left renal pelvis. 2. Punctate nonobstructing left renal stones. No hydronephrosis. 3. Bilateral perinephric stranding is nonspecific, but can be seen in the setting of infection recommend correlation with urinalysis. 4. Thickened urinary bladder, may be due to underdistention, however recommend correlation with urinalysis. 5. Cholelithiasis without evidence of acute cholecystitis. 6. 1.5 cm cystic lesion in the uncinate process of the pancreas. Recommend nonemergent MRCP if previous workup has not been performed. 7. Small pericardial effusion. RECOMMENDATION(S): 1.5 cm cystic lesion in the uncinate process of the pancreas. Recommend nonemergent MRCP if previous workup has not been performed. The patient was diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic. The patient was treated with L PCN exchange (___). At the time of discharge, the patient had Pyelonephritis, Catheter associated UTI. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ h/o lumbar spinal injury, marked b/l ___ weakness, multifactorial CKD stage IV (b/l Cr ~2.1-2.3), obstructive uropathy w/ chronic Foley, L ureteral stricture s/p L PCN, recent admission to ___ ___ for UTI (ESBL E.coli and Stenotrophomas, s/p treatment with Ceftaz/Bactrim) presenting with b/l flank tenderness, imaging suggestive of b/l pyelonephritis and cystitis. UCx grew Pseudomonas and Corynebacterium, for which he will complete two week course of Daptomycin/Zosyn. S/p Foley and L PCN exchange. # Bilateral pyelonephritis: # Urinary retention (with chronic Foley): # L ureteral stricture s/p L PCN: Mr. ___ was recently admitted ___ with E.coli/Stenotrophomonas UTI, treated with Bactrim/Ceftaz, with subsequent UCx in ___ again positive for those organisms (for which he was evaluated by ID, with decision not to treat given presumed colonization). He presented this admission with b/l flank tenderness, malaise, WBC 9.4, and a CT scan with fat stranding c/w cystitis and b/l pyelonephritis with no hydronephrosis. He underwent a Foley exchange and a L PCN exchange ___. He was initially restarted on Bactrim/Ceftaz and ID was consulted. When UCx from admission grew MDR Pseudomonas and Corynebacterium (not urealyiticum per micro lab), he was transitioned to Vanc/Cefepime (despite Pseudomonas with only intermediate sensitivity to cefepime). Subsequent sensitivity testing showed sensitivity with Zosyn and Ciprofloxacin; given prolonged QTC, Cefepime was transitioned to Zosyn. A midline was placed on ___ for access. Given inability to administer Vancomycin through a midline, ID recommended transitioning Vancomycin to Daptomycin (rather than replacing midline with PICC). He will continue a 2 week course of Daptomycin 300mg IV q24h and Zosyn 4.5g IV q12h (per ID pharmacy recommendations given urinary source and infeasibility of home q6 or q8h dosing), ___. He was discharged home with home infusion services; daughter ___ (a ___) will administer antibiotics. ID ___ is scheduled for ___. In addition, patient will transfer urology care to ___ for consideration of L ureteral stenting (appointment scheduled for this month). L PCN exchanged scheduled for ___ with ___. Of note, suppressive UTI therapy has been considered by ID and thought suboptimal (oral B-lactams inadequate, fosfomycin resistance on ___ cultures, suspected nitrofurantoin ___, inability to use methenamine given CKD, TMP/SMX wouldn't cover known organisms and would risk nephrotoxicity). # Acute on chronic CKD stage IV: # Non-gap metabolic acidosis: Followed by Dr. ___ for multifactorial CKD stage IV (thought due to AIN, obstructive uropathy, IgA nephropathy). Baseline Cr appears to be 2.1-2.3, 2.6 on admission, likely pre-renal, and improved to 2.3 at discharge. Home prednisone 2.5mg daily was continued. HCO3 19 on discharge; initiation of sodium bicarbonate deferred to outpatient nephrologist, Dr. ___ scheduled for ___. # Afib: # Possible CHB with junctional bradycardia: Patient with hx of afib on Coumadin with EKG suggestive of possible complete heart block with narrow junctional escape in the ___. I spoke with the patient's former cardiologist (Dr. ___ at ___, who last saw patient in ___ while the patient was hospitalized. Dr. ___ that this rhythm dates back to ___. Given stability, Dr. ___ PPM placement. ___ EP was consulted this admission and recommended outpatient ___ given stability. Patient remained asymptomatic and HD stable. Coumadin was held initially for procedures and subsequently resumed. Given CHADs2=1, he was not bridged. He received Coumadin 5mg on ___, 5mg on ___, 5mg on ___, and 3.5mg on ___. He was discharged on Coumadin 5mg daily and will resume Coumadin monitoring through the ___ Anticoagulation Management Clinic (___) after discharge. Next INR should be checked on ___ (1.6 on discharge) by ___. Patient requested that cardiology care be transitioned to ___ he was scheduled for ___ with Dr. ___ on ___. # Normocytic anemia: Hgb 11.9 on admission. Patient has chronic anemia dating back to ___ (b/l appears to be ~8), for which he has intermittently required transfusions and was recently seen by hematology (Dr. ___ on ___. Thought secondary to CKD and low Epo vs MDS. ___ was deferred, and Procrit 40,000u weekly was initiated (held in-house). Hgb stable while hospitalized, 10.2 on discharge. # Hyperkalemia: K peaked at 5.4 on ___, likely in setting of captopril initiation for hypertension (see below). Captopril was discontinued, and K improved to 5.2 on discharge. Would benefit from repeat BMP at PCP ___. # HTN: Intermittently hypertensive this hospitalization to SBPs 180s (without evidence of end organ damage) in absence of clear pain or anxiety. Home HCTZ was continued. Home amlodipine was uptitrated to 10mg daily, continued at discharge. Captopril was briefly trialed with plan to transition to long-acting ACE-I, discontinued for hyperkalemia as above. BPs improved, particularly on manual rechecks, and further titration of anti-hypertensives was deferred to patient's PCP and nephrologist. Of note, B-blockers should be avoided going forward given bradycardia. # Hypothyroidism: Continued home levothyroxine. # HLD: Held home statin on discharge pending completion of daptomycin course. To be resumed by PCP. # Anxiety: Continued home sertraline and lorazepam. # Gout: Continued home allopurinol. # Pain ___ prior crush injury Continued home oxycodone 10mg q6h PRN and oxycontin 10mg BID with hold parameters. # Pancreatic cyst: Incidental 1.5 cm cystic lesion in the uncinate process of the pancreas seen on CT. ___ as outpatient with non-emergent MRCP. ** TRANSITIONAL ** [ ] Daptomycin 300mg IV q24h and Zosyn 4.5g IV q12h, ___. [ ] INR on ___ call results to ___ Clinic ___ [ ] repeat BMP to monitor K at PCP ___ [ ] consider sodium bicarb initiation if metabolic acidosis persists [ ] resume statin after completion of daptomycin course [ ] trend BPs; adjust anti-hypertensives as needed [ ] MRCP for incidentally seen cystic lesion in uncinate process [ ] consideration of PPM </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with Type 2 diabetes mellitus complicated by neuropathy, prior strokes and ___ transferred from ___ with troponin 0.04, ? evolving ST changes in V2-V3 increasing in the setting of increasing chest pain with concern for NSTEMI. Patient's outside labs were significant for Hct 21, hypokalemia and hypocalcemia. Patient was given ASA and pRBCs and was guaiac negative. Patient is wheelchair bound at baseline with many prior strokes. The patient's most recent coronary angiography was at ___ which was done after a negative ETT. He had only one 50% LAD lesion. Patient presented with intermittent chest pain since the night before Qunicy admission, which became persistent in AM, so he was brought to QH by EMS. There was no report of dyspnea or cough. Initial troponin was 0.048, Ca 5.5, alb 1.9, Hct 21.1. CXR was unremarkable. Per QH notes, he had minimal EKG changes compared with prior and was pain free in their ED. It was decided to transfer the patient to ___ for possible coronary angiography. Radiology showed Findings suggesting vascular congestion. Radiology showed No acute intracranial process. The patient was diagnosed with CHEST PAIN NOS. The patient was treated with Cardiac catheterization and deployment of a drug-eluting stent in the high ___ diagonal branch. At the time of discharge, the patient had Primary: Non-ST segment myocardial infarction Secondary: Coronary artery disease Hypertension Diabetes mellitus, type II, with neuropathy Prior cerebrovascular accidents Gastroesophageal reflux disorder Anxiety Depression Seizure disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with Type 2 diabetes mellitus complicated by neuropathy, multiple prior strokes and HCV who was transferred from ___ ___ with chest pain, EKG changes and biomarker elevations consistent with NSTEMI. # NSTEMI/CAD: Patient presented with chest pain, troponin elevation, and some EKG changes, all consistent with NSTEMI. He was treated with heparin gtt, nitro gtt, morphine, beta-blocker, ACE-I, aspirin, and statin (changed from simvastatin to atorvastatin) and was rendered pain free after arrival to the ___. He underwent echocardiography, which showed mild left ventricular hypertrophy, but no regional wall motion abnormalities. Since the patient occasionally became somewhat agitated and there was concern about his ability to cooperate by lying still during a prolonged procedure, cardiac catheterization was deferred for several days until the procedure could be performed under MAC coverage by anesthesia. Cardiac catheterization on ___ showed LVEDP 18-20 mm Hg, diffuse mild disease (including a 50% stenosis in the mid RCA), with a 90% ostial stenosis of the ___ diagonal branch. A DES was placed in this location, and he was discharged on full-dose aspirin and Plavix. # Fall: He had an unwitnessed fall on the morning of discharge. Head CT performed shortly thereafter was negative for any acute intracranial process. # Laboratory artifact: In retrospect, the initial laboratory values from ___ were likely artifactual, possibly diluted. The patient's Hct recovered too well and too quickly after 1 unit of pRBCs, and his hypokalemia and hypocalcemia also normalized very quickly.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with a history of HTN, newly diagnosed with a T9 compression fracture that was biopsied on ___, revealing plasma cell neoplasm CD138+ and kappa LC restricted. He started XRT to T9 on ___, and saw Dr. ___ primary oncologist at ___, where he had a bone marrow on ___ that revealted 10% plasma cells. He was started on Zometa, and referred to ___ for a ___ opinion for systemic treatment. CT ABD AND PELVIS WITH CONTRAST showed 1. Fat stranding at the level of the GE junction likely reflects gastritis seen on the EGD from the outside hospital. This could also be non-specific change from prior radiation therapy. The stomach itself is not well distended, limiting evaluation. 2. The appendix is dilated to 10 mm, although without adjacent fat stranding or fluid collection. Oral contrast fills the cecum, but not the appendix. While outside hospital images are not available for review, based on the outside hospital report, today's appearance of the appendix is presumed to be similar to the scan from 3 days prior. 3. Known multifocal lytic lesions of T8, L4, and the left iliac bone, compatible with known history of multiple myeloma. Near complete collapse of the T9 vertebral body was also identified on the prior study. NOTIFICATION: The above findings were communicated in person by Dr. ___ to Dr. ___ resident) at 06:55 on ___. CT CHEST W/O CONTRAST showed 1. Nonspecific ill-defined perigastric fat stranding posterior to the left liver lobe at the level of the GE junction appears unchanged from ___. Again, this may reflect gastritis but appears to be within the radiation treatment field. Proximally the esophagus appears unremarkable. 2. Relative regional hypodensity of the left hepatic lobe is unchanged, and likely reflects sequela of radiation treatment. Multiple hepatic hypodensities measuring up to 1.3 cm are stable, and likely represents cyst or biliary hamartomas. 3. Vertebral plana of T9 and lytic lesion in the inferior endplate of T8 again seen. MR ___ ANDW/O CONTRAST ___ MR SPINE showed 1. Multiple osseous lesions, likely secondary to multiple myeloma. 2. Pathologic fracture at T9 leading to vertebra plana and associated spinal canal and neural foramen stenosis causing impingement of T10 nerve root. 3. Postradiation changes involving T6- T11 vertebral bodies with fatty infiltration. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, NAUSEA. At the time of discharge, the patient had Abdominal pain due to T9 Lesion H.pylori/gastritis Multiple myeloma Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY ___ M with new MM (diagnosed ___, s/p XRT to T9 on ___, never had chemo) who presented with 2 months of epigastric pain, much worse in the past week. Initially, pain was thought to be ___ gastritis because of location, and EGD at OSH showed mild gastritis. Upon further examination, discovered that pain followed a T9 distribution from his vertebra, along ribs laterally, to his epigastrum. MRI on ___ showed T9 vertebral plana with canal narrowing, so pain is likely neuropathic from cord compression. Pain was controlled with Fentanyl patch, Gabapentin, and prn Dilaudid; patient also took Protonix & Ranitidine for his gastritis. He was found to be positive for H.pylori, and thus was started on triple therapy for 14 days for treatment. ACTIVE ISSUES #ABDOMINAL PAIN: Originally, the patient reported severe epigastric pain, which was thought to be ___ gastritis. EGD at OSH showed mild gastritis, but this did not fit with the severity of the patient's symptoms. Radiation effect was also considered, but the timeline didn't fit, because radiation gastritis/edema typically occurs ___ after XRT, then improves. Patient also received Protonix & Ranitidine for gastritis. He was found oto be H.pylori positive, with triple therarpy started ___ in pm:Pantoprazole 40mg po BID, Clarithromycin 500mg BID, Amoxicillin 1 g BID for ___ (stop date ___. #T9 Compression Fracture: Patient has tenderness along the T9 distribution, where he has known MM involvement. His was tender along his T9 spine, around both ribs, and ending in epigastric pain. MRI on ___ showed vertebral plana of T9 with focal kyphosis, which is the likely cause of patient's symptoms. He was assessed by orthopedics who saw no current indication for spine surgery. Given minimal low back pain and that he was ambulating well, he had no need for TLSO brace with plan to follow up with Dr. ___ in 1 month if pain persists. He was stated on gabapentin, continued this Gabapentin 300mg TID, which helped the patient's pain signifcantly. He was also continued on a Fentanyl patch and Dilaudid PO ___ mg PO/NG Q3H:PRN severe pain. # Multiple Myeloma: Patient was diagnosed in ___, and received XRT to T9 lesions in ___. He has never received chemotherapy. His lab studies shows IgG 1280, IgA 240, IgM 58. He was scheduled for appointments with his oncologists for the day after discharge. #CONSTIPATION: Patient was initially consipated given substantial narcotics needs for pain. He was given Docusate and Senna, with Miralax and Bisacodyl as needed, and resumed having regular BMs. # Hypertension: Given overalln normal blood pressures, home Lisinopril was held while in house.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ known nephrolithiasis history w/ R flank pain and nausea. He notes stubborn pain over recent days culminating in worsening pain today with some associated nausea. ROS demonstrates dysuria. Vital signs within normal limits; patient well-appearing. PE demonstrates no flank pain b/l; minimal abdominal pain. ___ shows no leukocytosis and creatinine to 1.7 from 1.2 (most recent baseline available in computer. ___ from several days ago shows <10K strep species. CTU shows obstructing right ureteral stone at ___ w/ moderate hydronephrosis and some associated perinephric stranding. Radiology showed 1. 5 mm obstructing stone at the right UVJ with moderate right hydronephrosis and perinephric stranding. 2. Diverticulosis without signs of diverticulitis. RETROGRADE UROGRAPHY (FILMS ONLY) IN CYSTO showed Intraoperative images were obtained during right retrograde urography and ureteral stent placement. Please refer to the operative note for details of the procedure. The patient was diagnosed with CALCULUS OF KIDNEY. The patient was treated with Right ureteroscopy with laser lithotripsy and placement of a double-J stent.. At the time of discharge, the patient had ACUTE KIDNEY INJURY (creatinine to 1.7) Right ureteral stone with obstruction and hydronephrosis.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to urology service for nephrolithiasis management with a known right ureteral stone with obstruction and hydronephrosis causing acute kidney injury with a creatinine to 1.7. He was admitted, given intravenous fluids and expulsive therapy but without nephrotoxic agents like Toradol. He had taken a Pyridium provided by outside provider from prior hospital visit for same complaints. No stone was passed overnight or since admission so he was made NPO and taken to the OR where he underwent right ureteroscopy with laser lithotripsy and placement of a double-J stent. Mr. ___ tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. He remained in observation on the general surgical floor until voiding well and without complaint. He was subsequently discharged home. At discharge, Mr. ___ 's pain was controlled with oral pain medications and he was tolerating a regular diet, ambulating without assistance, and voiding without difficulty. He was given antibiotics and pain medications on discharge with explicit instructions to follow up as directed as the indwelling ureteral stent must be removed and or exchanged.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ R handed gentleman with a past medical history significant for hyperlipidemia, htn, CAD, diabetes mellitus type II, and recently diagnosed R temporo-parietal infarct treated at ___. He presents today as a transfer from ___ after he had an "interval follow up ct scan" to evaluate his stroke which revealed concern for possible hemorrhage prompting transfer to ___. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Large subacute infarct involving the right parietal lobe, temporal lobe, and posterior insula, with hemorrhagic transformation, plus/minus pseudolaminar necrosis. 2. Additional smaller right anterior lobe infarct with hemorrhagic transformation plus/minus pseudolaminar necrosis, also subacute, which appears to be older than 10 days. 3. Patchy small subacute infarctions in the right posterior inferior cerebellar hemisphere. 4. Small focus of cortical subacute infarction in the right posterior frontal lobe. 5. Contrast enhancement associated with above described subacute infarctions is likely physiologic, but follow-up imaging is recommended to ascertain resolution. 6. The above described infarctions of varying ages in multiple vascular territories suggest embolic etiology. RECOMMENDATION(S): Follow up MRI with and without contrast in approximately 6 weeks to confirm expected resolution of contrast enhancement. The patient was diagnosed with Nontraumatic subarachnoid hemorrhage, unspecified. At the time of discharge, the patient had Subacute infarcts due to LV thrombus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ R handed gentleman with a past medical history significant for hyperlipidemia, htn, CAD, diabetes mellitus type II, and recently diagnosed R temporo-parietal infarct treated at ___. He presents today as a transfer from ___ after he had an "interval follow up ct scan" to evaluate his stroke which revealed concern for possible hemorrhage prompting transfer to ___. CT scan showed an area of hyperdensity in a linear/ribbon-like fashion concerning for possible SAH vs. Cortical laminar necrosis prompting transfer to ___. He was previously found with a large LV thrombus at ___ but he was not discharged on anticoagulation due to concern for hemorrhagic conversion. On this admission, his exam was mostly nonfocal except for anisocoria and mild inattention. MRI found "large subacute infarct involving the right parietal lobe, temporal lobe, and posterior insula, with hemorrhagic transformation, plus/minus pseudolaminar necrosis. Additionally, there was smaller right anterior lobe infarct with hemorrhagic transformation plus/minus pseudolaminar necrosis, also subacute, which appears to be older than 10 days. There was also patchy small subacute infarctions in the right posterior inferior cerebellar hemisphere. Small focus of cortical subacute infarction in the right posterior frontal lobe." TTE showed LVH, severe distal anterolateral hypokinesis, large LV apical thrombus. Plavix was held but ASA continued. Patient was started on Coumadin 5 mg daily. He understands importance of compliance with his meds & the need to monitor warfarin/INR closely. He also stated that his sister "keeps a very close eye on him". Spoke with his outpatient neurologist, Dr. ___ agreed with AC. Transitional Issues: []INR checks by VNS initially and at PCP ___ []PCP ___ on ___ at 12 pm. []Neurology ___ in next ___ weeks. Office will contact patient. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No. If no, reason why: 2. DVT Prophylaxis administered? () Yes - (x) No. Hemorrhagic transformation. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? () Yes - (x) No. If not, why not? Hemorrhagic transformation (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL = 104) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - atorvastatin 40mg () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - () No [reason (x) non-smoker - recently quit, on nicotine patch () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old female who complains of n/v/d. Hx SBO, s/p recent ventral hernia repair s/p SBO 5d PTA, discharged yesterday, presenting with abdominal pain, nausea, vomiting, and profuse watery diarrhea. She has typically had diarrhea associated with her SBO. No fever/schills. NBNB emesis. Not tolerating po. Decreased flatus. CT ABD AND PELVIS WITH CONTRAST showed 1. Intra-abdominal fluid collection posterior to the surgical mesh measuring 13.0 x 2.4 cm, concerning for a developing abscess. Markedly edematous, mildly dilated loops small bowel posterior to this collection are probably reactive (vs enteritis or ischemia.) 2. Soft tissue fluid collection within the anterior abdominal wall soft tissues with surrounding stranding, is likely postsurgical although a superimposed infection is not excluded. 3. Fluid-filled large bowel without evidence of thickening. Radiology showed No radiographic evidence of pneumonia. Radiology showed Successful US-guided aspiration of a superficial right lower quadrant fluid collection, yielding 50 cc of sanguineous fluid. Samples were sent for microbiology evaluation. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. The patient was treated with ___: Successful US-guided aspiration of a superficial right lower quadrant fluid collection. At the time of discharge, the patient had intra-abdominal fluid collection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the hospital 24 hours after discharge with nausea, vomiting, and abdominal pain. Her white blood cell count was reported at 20. Upon admission, the patient was made NPO, given intravenous fluids, and underwent cat scan imaging of the abdomen which showed an intra-abdominal fluid collection posterior to the surgical mesh measuring 13.0 x 2.4 cm. This was concerning for a developing abscess. The patient was started on intravenous vancomycin and zosyn. The patient then underwent ___ drainage of the fluid collection where 50 cc of sanguineous fluid was removed and sent for culture. The patient's vital signs remained stable and she was afebrile. She was tolerating a regular diet and voiding without difficulty. Her white blood cell count decreased to 10. Because the diarrhea persisted, a stool culture for c.diff was sent which was negative. The patient was discharged home with ___ services on HD #3 in stable condition. The patient was transitioned to oral antibiotics for 1 week. Post-operative instructions were reviewed. A follow-up appointment was made with the acute care clinic. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of cirrhosis secondary to alcoholic liver disease and hep C who presents with worsening ascites and lower extremity swelling. Pt reports that he began having cough with subjective fevers/chills on ___, associated with pain underneath his shoulder blades bilaterally and shortness of breath. His cough was productive of green mucous. Pt reports a Tmax at home of 103.3 on ___. That afternoon, he presented to ___ for a therapeutic tap, where 3 liters of ascitic fluid was reportedly removed. Pt told staff there that he was feeling unwell, but was told that his blood work was normal and he was discharged home. He presented again to the ___ ED on ___ and was reportedly diagnosed wtih pneumonia and started on azithromycin. He reports no improvement since starting on azithro. Since ___, he notes worsening of his lower extremity edema and abdominal distension, associated with diffuse abdominal tenderness. Pt called Dr. ___ for an appointment but stated that he needed to be seen today, so presented to the ED. . Pt was hospitalized ___ for hematemesis with negative EGD. Bleeding was attributed to epistaxis. No evidence of variceal bleed. He was discharged on 7 day course of ciprofloxacin. . ED Course: Initial Vitals 97.7 57 ___ 99% ra. CXR showed stable persistent patchy L basilar opacity wo acute findings. He underwent diagnostic paracentesis which showed WBC 140, RBC 845, tot protein 1.3, gluc 126, 7% PMN. Labs notable for lactate 1.8, wbc 6.8 (wo L shift), Hct 40.7, Plt 70, chem 7 wnl, AST 109, ALT 45, tbili 1.3, alb 2.8. He received ceftriaxone 1g IV to broaden for presumed pna, IV morphine, and zofran. Vitals prior to transfer 97.8 °F (36.6 °C), Pulse: 62, RR: 18, BP: 110/79, O2Sat: 97, O2Flow: ra, Pain: ___. Access: PIV 20g. . On the floor, pt reports feeling improved since getting ceftriaxone in the ED. He states that his leg and abdominal swelling is only mildly increased and his biggest concern has been his cough, nasal congestion and headaches. He also note 1 day of diarrhea and vomitting last ___. Pt reports that he has been compliant with medications, and compliant with a low salt diet. He has been requiring therapeutic taps every 2.5 weeks. Radiology showed Mild suspected background interstitial abnormality and unchanged focal left infrahilar opacity, accordingly suggestive of longer chronicity. Clinical correlation is recommended. If shortness of breath were to continue and the possibility of an underlying interstitial process is of potential clinical concern, dedicated chest CT could be considered. Radiology showed 1. Cirrhosis with findings consistent with portal hypertension including splenomegaly and varices. 2. Moderate-to-large quantity of ascites. 3. Fat-containing ventral hernia with a fairly wide neck. Although there is increased attenuation of fat as well as a small quantity of peripheral fluid, which can be seen with incarceration, findings are highly nonspecific in this setting. The patient was diagnosed with OTHER ASCITES, HYPERTENSION NOS, LIVER DISORDER NOS. The patient was treated with diagnostic paracentesis. At the time of discharge, the patient had PRIMARY: abdominal pain SECONDARY: hepatitis C Cirrhosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man with a history of cirrhosis secondary to hepatitis C and alcohol use who was admitted with fever and abdominal pain. Pt remained afebrile throughout his stay and his abdominal exam and imaging were not concerning for any acute process. . </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with metastatic lung cancer with progressive brain metastases s/p metastasis resection and craniotomy ___ for brain met felt to be causing intractable nausea/vomiting who started fraction 1 of 5 of whole brain radiation therapy today ___ now presenting with chief complaint of nausea, vomiting and headache. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Compared to ___, the extent of edema associated with bilateral supratentorial and left cerebellar metastases has increased, statistically likely secondary to radiation therapy. There is only mild new effacement of the atrium of the right lateral ventricle, but no other significant mass effect. 2. No evidence for acute hemorrhage. The patient was diagnosed with Headache. The patient was treated with Whole brain radiation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with metastatic lung cancer with progressive brain metastases s/p metastasis resection and craniotomy ___ for brain met felt to be causing intractable nausea/vomiting who started fraction 1 of 5 of whole brain radiation therapy today ___ now presenting with chief complaint of nausea, vomiting and headache concerning for radiation induced edema (treatment effect). # nausea/vomiting/headache - Suspected sequelae of too rapid a taper of dexamethasone. Headache improved rapidly with steroids. Patient was discharged on an long dexamethasone taper. # Abdominal pain - Improved with a bowel movement. Started on ranitidine and simethicone for "fullness" with improvement in sypmtoms. On discharge she was able to tolerate a regular diet. # Lung cancer - plan had been to try nivolumab/immunotherapy but currently pursuing WBRT as recently found to have progression of intracranial mets; s/p resection of one large met earlier in ___. Received ___ days of whole brain radiation while hospitalized. Final day will be ___. She will follow up with oncology as an outpatient. # H/O DVT: continued on home lovenox.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ HLD, HTN, OSA, PNET s/p distal pancreatectomy/splenectomy (___) w/ recent hospitalization (___) w/ abdominal abscess requiring JP drain and PE (warfarin) who p/w hypoxemia and AMS. Radiology showed Dense left basilar opacity likely combination of effusion with atelectasis noting superimposed infection would be possible. Enlarged cardiac silhouette potentially due to combination of cardiomegaly and/or pericardial effusion. Pulmonary vascular congestion. Enteric tube off the inferior field of view. Radiology showed The tip of the endotracheal tube projects over the mid thoracic trachea. An enteric tube projects over the stomach. There is the tubing catheter which projects over the left hemithorax. There is an unchanged moderate to large left pleural effusion with subjacent atelectasis. The right lung is grossly clear. The size of the cardiac silhouette is enlarged. Radiology showed The tip of the endotracheal tube projects 1.4 cm from the carina and should be retracted by approximately 1 cm. The tip of a new right internal jugular central venous catheter projects at the level of the mid SVC. Unchanged cardiopulmonary findings. Findings were communicated to and acknowledged by the patient's nurse at 22h37 by ___, MD. CT-GUIDED DRAINAGE CATHETER PLACEMENT. showed Successful CT-guided placement of ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation. Radiology showed No acute fractures or dislocations are seen. There are severe degenerative changes the first CMC and triscaphe joints. There is normal osseous mineralization.Chondrocalcinosis is seen. Radiology showed Endotracheal tube has been removed. There is a feeding tube and right IJ central line which are in unchanged position. There is cardiomegaly. There is a left retrocardiac opacity. There is mild pulmonary edema, stable. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are essentially unchanged, as is the appearance of the heart and lungs. Portable chest x-ray showed Cardiomegaly. Increased left retrocardiac density. Mild pulmonary edema appear CHEST (PORTABLE AP) showed Right internal jugular line tip is at the level of superior SVC. Heart size and mediastinum are unchanged. There is interval improvement, at least partial of the left retrocardiac atelectasis and more central position of the mediastinum. There is mild vascular congestion but no overt pulmonary edema. No pneumothorax. Radiology showed Dobhoff tube projecting over the left mid abdomen in expected position. Cannot exclude the Dobhoff is within the gastric lumen, however it appears in similar position to prior CT from ___. CHEST (PORTABLE AP) showed In comparison with the study of ___, the tip of the right IJ catheter again extends to the level of the carina in the upper to mid SVC. Cardiomediastinal silhouette is stable and there again is mild vascular congestion. Increased opacification at the left base with obscuration of the hemidiaphragm is consistent with pleural fluid and volume loss in the left lower lobe. No evidence of acute focal pneumonia. Radiology showed No pneumothorax is identified. Persisting small left pleural effusion with subjacent atelectasis. CT ABDOMEN/PELVIS WITH CONTRAST. showed 1. The 2 more lateral catheters in the left upper abdomen appear in good position. Given the thick consistency of the left upper abdominal collection, up sizing and repositioning the left most lateral drain can be considered. Another potential way of drainage would be through endoscopic placement of a drain through the stomach, for which gastroenterology service consultation would be considered to determine feasibility. 2. The most medial drain can be removed as it does not terminate in any collection. 3. Minimal decrease in size of left upper abdominal gas containing collection. Up sizing the left most lateral catheter can be considered as well as repositioning it more cranially and posteriorly. 4. Decreased size left diaphragmatic crus collections with no drains in place. 5. Decreased left side pleural fluid. Radiology showed 1. Successful CT-guided repositioning of a 12 ___ pigtail catheter into the left upper quadrant collection. 30 mL of purulent fluid was aspirated. The cavity was irrigated till clear fluid return noted. Postprocedure images demonstrated a small residual collection in the most dependent portion of this collection which as the patient moves around should be drained via the existing position of the pigtail. 2. The midline 12 ___ drainage catheter was not removed as a small amount of purulent fluid was noted within the JP drain connected to this catheter. 3. The patient with stood the procedure well and was transferred back to the floor in a hemodynamically stable condition. The patient was diagnosed with Sepsis, unspecified organism. The patient was treated with Pericardiocentesis Left thoracentesis Abdominal JP drain insertion Intubation, extubation Right IJ line placement, removal. At the time of discharge, the patient had Pancreatic ___ Tumor ___ infection Diabetes mellitus Pericardial effusion Pleural effusion Atrial fibrillation Pulmonary embolism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>HOSPITAL COURSE =============== Mr. ___ is a ___ M with HTN, HLD, OSA, afib, PNET s/p distal pancreatectomy/splenectomy (___) w/ recent hospitalization (___) for pancreatic fistula and a PE, who presented from rehab with hypoxia and AMS, course complicated by pericardial and pleural effusions. ACTIVE ISSUES ============= # Pancreatic fistula # PNET s/p distal pancreatectomy/splenectomy: Patient presented to the hospital with two JP drains in place. He was persistently febrile on Zosyn (___), thus a third abdominal drain was placed by ___ on ___. Afterwards the patient was largely afebrile. ID was consulted and gave abx recs. Continued Zosyn for 2 week total course from drain placement on ___, last day ___. Repeat CT ___ showed persistent LUQ fluid collection. Repositioned LUQ JP drain with ___ on ___. Stable at discharge, still with 3 JP drains, will f/u with surgery in ___ weeks and continue tube feeds and clear liquids until that time. # Left Pleural effusion: During ___ admission patient had bilateral pleural effusions attributed to ___. However, now this admission was unilateral and persistent despite diuresis. S/p thoracentesis by IP on ___ with fluid studies suggestive of an exudative effusion, Gram stain negative for microorganisms. Cytology negative for malignant cells. Rheumatology feels unlikely systemic rheum disorder, more likely related to abdominal infection/inflammation. Negative ___, RF. Will f/u in ___ clinic. # Pericardial effusion: Patient presented with large pericardial effusion seen on admission with tamponade physiology. Underwent pericardiocentesis on ___ with drainage of 470ml sanguineous fluid. Cytology without malignant cells. Total nucleated cells # ___. No recurrence of symptoms. # Prior PE # Atrial fibrillation: Diagnosed with both atrial fibrillation and PE during ___ admission, started on warfarin. During ICU course was on heparin gtt. Heparin gtt transitioned to Lovenox on ___. Will continue Lovenox ___ BID. Received Metoprolol Tartrate 25 mg PO/NG Q6H inpatient, transitioned to Metoprolol Succinate 100 mg PO/NG DAILY on discharge. CHRONIC ISSUES ============== # Chronic pain - Continued Acetaminophen 500 mg PO/NG Q6H:PRN Pain - Continued OxycoDONE Liquid 5 mg PO/NG Q4H:PRN - Continued OxyCODONE SR (OxyconTIN) 20 mg PO Q12H # Diabetes: Patient received Lantus 20U Nightly with Humalog sliding scale, BG still not completely controlled on discharged, BG ___, should be titrated up by PCP. # BPH: Admitted with Foley due to urinary obstruction with failed voiding trial last admission. Foley pulled ___, able to void. Continued tamsulosin 0.4 mg PO QHS. # HLD: Continued Simvastatin 20 mg PO/NG QPM. # GERD: Continued Pantoprazole 40 mg PO Q24H. RESOLVED ======== # Delirium: Multifactorial given medical problems above. # OSA # Hypercarbia: Presented with hypercapneic respiratory failure in the setting of an acute illness, encephalopathy, opioid use, shock, enlarging pericardial effusion, and persistent left pleural effusion. Intubated < 24 hours with intermittent BIPAP. Resolved, patient on room air by discharge. TRANSITIONAL ISSUES =================== [] PCP to follow up patient blood sugar, titrate up Lantus and/or short acting insulin if consistently hyperglycemic [] Patient to continue current tube feed regimen with only clear liquids by mouth [] JP drains #2 and #3 to be flushed 4 times a day with normal saline [] Appointments - PCP - ___ - ___ Pulmonology - Surgery ___ with Dr. ___ arranged. Patient to call ___ to set up an appointment time in the next ___ weeks. [] New medications - Metoprolol Succinate 200 mg PO DAILY - Enoxaparin Sodium 100 mg SC Q12H - Insulin (Glargine) 20 Units at Bedtime [] Stopped medications - Metoprolol Tartrate 50 mg PO Q6H - Creon 12 6 CAP PO Q8H - Diltiazem 30 mg PO Q6H - Warfarin I have seen and examined Mr. ___, reviewed the findings, data, and plan of care documented by Dr. ___, MD dated ___ and agree with the discharge summary and plan. ___, MD, PharmD Section of Hospital Medicine ___ ___ ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PCP: ___ HPI: ___ with h/o of lap band in ___, and partial nephrectomy for incidentally discovered renal mass (path: clear cell RCC) in ___ (___) with several recent hospitalizations for PNA who now presents with increased SOB and new acute renal failure. To summarize recent hospitalizations, she reports fevers/chills 1mo prior when she was admitted to OSH and discharged on Levaquin. Her symptoms recurred 3 weeks later when she was admitted to ___ with PNA, felt to be likely aspiration, and treated with IV Abx and discharged on ___ ___, with PICC line to recieve course of Vanc/Zosyn to finish on ___ per OSH records. Boyfriend has been administering infusions at home. Since that time she endorses SOB at baseline (on home 2L O2 since d/c from ___ on ___, no fevers, +fatigue. Endorses moderate fluid intake, denies any changes in bowel habits, urinary frequency, hematuria, or dysuria. Does endorse feeling bloated. Radiology showed Lingular and left lower lobe consolidation worrisome for pneumonia, new since the prior study. New small left pleural effusion. Subtle right basal opacity similar compared to prior. Recommend followup to resolution. Radiology showed Normal position of the gastric band with patent stoma. Radiology showed Extensive predominantly lingular and left lower lobe parenchymal opacity that suggests chronic infection and is accompanied by a small pleural effusion. No morphological reason for these changes can be identified, notably there is no evidence of focal airway narrowing or airway obstruction. Mild chronic airways disease and moderate right upper lobe predominant pulmonary emphysema, with several mostly ground-glass nodules (the biggest of which measures 5 mm in diameter and is located in the right upper lobe) that should be followed in approximately three months. Unchanged areas of atelectasis at the right lung base. Mild pericardial effusion, moderate-to-severe coronary calcifications. Mild aortic valve calcifications. Right PICC line. No mediastinal adenopathy. Status post gastric banding, mild hiatal hernia. Radiology showed No evidence of aspiration. Small amount of penetration. Radiology showed No evidence of deep vein thrombosis in either the right or the left lower extremity. The patient was diagnosed with SHORTNESS OF BREATH. The patient was treated with ___: Emptying of lap band by bariatric surgery: 1cc removed, emptying the band completely ___: Right heart catheterization. At the time of discharge, the patient had Aspiration PNA. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo female with hx of lap band ___, partial nephrectomy for ___, and several recent hospitalizations for PNA now presenting with shortness of breath and ___. # Shortness of breath- Patient complained of worsened shortness of breath, though improved since presentation to OSH. CXR demonstrated new opacity, OSH CT revealed multifocal nodular infiltrate in lower left lobe and lingula. She was started on a course of IV Vancomycin and Zosyn while hospitalized at ___ ___, per OSH records to finish on ___. However, vancomycin trough on ___ was 74, so vanco was discontinued. She did recieve Zosyn until ___ given continued inability to wean O2 (described below). She had a speech and swallow evaluation ___, where it was felt that her symptoms of reflux were consistent with post-prandial regurgitation in the setting of lap band, which improved per patient report after lap band fluid removal. 1cc was removed from the band on initial admission (in the ED) by bariatric surgery, and UGI study following this procedure revealed no obstruction. The patient's symptoms resolved to baseline, which she states is chronically mildly short of breath. However, she did continue to have an O2 requirement which proved difficult to wean, with continued desaturations to low ___ while ambulated on RA, so pulmonology was consulted. Initiated hypoxemia workup which included ABG which revealed pO2 57 PCO2 39 pH 7.49. Bglucan neg, antiGBM neg. ECHO was performed, revealing moderate pulmonary artery systolic hypertension; subsequent right heart cath demonstrated elevated right and left sided filling pressures and moderate to severe pulmonary hypertension. Additionally, rheumatologic workup revealed ___ neg, RF neg, ANCA neg, ___, antiCCP neg. Bronchoscopy or further imaging were deferred at this time. The patient was discharged satting >92% on 2L, and has follow up in place with cardiology, pulmonology, and will need follow up imaging in ___. # Hx lap band, anorexia- Pt underwent removal of 1cc from lap band; she tolerated the procedure well. As above, upper GI revealed no e/o leak or slippage on imaging. As above, her symptoms of reflux improved after the procedure, and she was maintained on a stage 3 bariatric diet while in house. # ___: While hospitalized, the patient's Cr was noted to be 2.9 (up from normal baseline 0.8-1.0). Bland urine sediment, UA negative. Elevated Cr was felt to be consistent with vancomycin associated toxicity in the setting of significantly elevated Vancomycin levels (trough 74). Vancomycin levels trended down to 7.9 at time of discharge. Cr initially trended upward to peak at 3.2, but came down to 2.3 at time of discharge. # Asthma- Patient was maintained on her home medications. #?history of IgG deficiency - In speaking with the patient's PCP, and mentioned in OSH records, the patient has a documented question of IgG deficiency. Workup was initiated while hospitalized with IGG 680* IGM 321 IGA 95. Levels of antiTB, antidiptheria, and antipertussis were obtained. # HTN- the patient's home betablocker and ASA were continued while in house. # CAD- per report pt with stent in ___, on ASA/B-blocker. Home simvastatin was discontinued upon admission given acute kidney injury, but was restarted upon discharge. # Code: full</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with PMH notable for EtOH dependence, opiate dependence, EtOH cirrhosis (no biopsy) c/b ascites, with recent admission (___) for abdominal pain, transaminitis and pancreatitis, with workup notable for unremarkable RUQ U/S (other than cirrhotic changes), EGD notable for chemical gastropathy w/o PUD/varices, who presents today with increased abdominal pain in the setting of recent 2 week EtOH binge. Patient presented to ED for further evaluation. Radiology showed 1. Cirrhosis with secondary findings of portal hypertension including reversal of portal venous flow and recannulization of the umbilical vein, as well as splenomegaly. Trace ascites. 2. Unremarkable gallbladder. The patient was diagnosed with ALTERED MENTAL STATUS , ALCOHOL ABUSE-UNSPEC, ABDOMINAL PAIN LUQ, ACUTE PANCREATITIS. At the time of discharge, the patient had Alcohol withdrawal Pancreatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo male with PMH notable for EtOH dependence, opiate dependence, EtOH cirrhosis p/w abdominal pain in the setting of recent 2 week EtOH binge, found to have transaminitis and elevated lipase consistent with alcoholic hepatitis and pancreatitis and in need of safe EtOH detox. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female who presents for left leg pain after a fall. She states that she tripped over her sandals today and fell onto her left side. She denies headstrike, LOC, CP, SOB. She feels well overall She has a hx of a remote R TKR ___ yearsr ago at ___) who was admitted this past ___ for repair of a femoral complete stress fracture, thought to be ___ bisphosphonate use. Her procedure was an intramedullary nail fixation Left intertrochanteric hip fracture on ___. DX TIB/FIB AND ANKLE/FOOT showed No fracture or dislocation. Radiology showed 1. Comminuted longitudinally oriented oblique fracture of the distal femoral shaft with mild anterior displacement and dorsal angulation of the distal fragment. 2. Small fissure-like fenestration in the anterior cortex of the proximal femur could represent a nondisplaced incomplete fracture, likely an early insufficiency fracture. 3. Interval healing of the known insufficiency fracture of the mid femoral diaphysis. Faint residual linear lucency is noted. 4. Intact intramedullary rod and total knee arthroplasty. No hardware loosening identified. 5. Linear lucency at the posterior edge of the anterior acetabular column is noted, without other findings to suggest acetabular fracture. FEMUR (AP AND LAT) LEFT IN O.R. showed As above. CHEST PORT. LINE PLACEMENT showed Compared to chest radiographs ___ through ___. New right internal jugular catheter ends in the upper right atrium approximately 2.5 cm below the estimated location of the superior cavoatrial junction. Borderline cardiomegaly. Lungs grossly clear. Pleural effusions small if any. No pneumothorax. Patient has had T AVR. The patient was diagnosed with Displaced oblique fracture of shaft of left femur, init, Displaced comminuted fracture of shaft of left femur, init, Fall on same level, unspecified, initial encounter. The patient was treated with ___ Internal fixation L distal femur.. At the time of discharge, the patient had periprosthetic fracture of L distal femur. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have periprosthetic fracture of L distal femur and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for Internal fixation L distal femur , which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to Rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is TWBB in the LLE, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with prior history of LIGB with radiation proctitis s/p APC therapy, AVM's, CAD s/p CABG and recent BMS (1 wk ago), prostate cancer s/p RT, bleeding internal hemorrhoids, cirrhosis d/t NAFLD, celiac's disease, pancytopenia, and iron-deficiency anemia (req. iv iron therapy) who presents with fatigue over 5 days. He has had black tarry stools for the past 3 days with some BRBPR today. While unclear, but he was found to have Hct of 29.3 on ___. Baseline Hct around ___. Radiology showed 1. Cirrhosis. No focal liver lesion. 2. Patent hepatic vasculature. 3. Splenomegaly. 4. No ascites. The patient was diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS. The patient was treated with EGD (___) Colonoscopy (___). At the time of discharge, the patient had Primary diagnosis: Gastrointestinal bleeding Secondary diagnoses: Cirrhosis, Esophageal Varices. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w several prior lower GI bleeds, NAFLD cirrhosis, pancytopenia, CAD s/p CABG & recent stents who p/w fatigue, melena ___ GIB now s/p ___ which did not show an active source.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo man with a history of CAD, inferior MI in ___ s/p DES to LCx, HTN, HLD, who was recently discharged on ___ with RUL CAP, on a course of levofloxacin, now returning with worsening shortness of breath for 3 days. CHEST (PORTABLE AP) showed Subtle opacity in the left lower lung is concerning for atelectasis versus an early pneumonia. Chest radiograph showed Subtle opacity persists in the left lower lobe concerning for pneumonia. The patient was diagnosed with Weakness. At the time of discharge, the patient had Primary --------- - Dyspnea of unknown etiology - SVT with aberrancy Secondary ---------- - Coronary artery disease s/p stent - Recent pneumonia - Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo man with a history of CAD, inferior MI in ___ s/p DES to LCx, HTN, HLD, who was recently discharged on ___ with RUL CAP, on a course of levofloxacin, now returning with worsening shortness of breath for 3 days. # Dyspnea His dyspnea had resolved at the time of transfer to the floor. Possibly was related to recent URI symptoms (rhinorrhea, cough, congestion) a few days prior to dyspnea. Pulmonary edema was unlikely given euvolemic on exam, recent TTE with normal EF, BNP < 450. Pneumonia was also unlikely given no fever, leukocytosis, or sputum production. CXR with streaky opacities on L lung that could represent atelectasis or pneumonia, but this was in the setting of recent pneumonia 3 weeks prior. Antibiotics were held. Angina/ischemia was also unlikely given EKG without ischemic changes, non-exertional nature of dyspnea, and negative troponin. # Rhythm Abnormalities: new atrial bigeminy, SVT with aberrancy The patient has no documented history of arrhythmia. In the ED, the patient had episode of bradycardia, thought to be in the setting of metoprolol administration. EKG revealed new atrial bigeminy. He was asymptomatic. He was kept on telemetry monitoring after transfer to the floor. On the morning after admission, he developed a 23-beat run of SVT with aberrancy in the 150s. He was asymptomatic. EKG was unchanged from admission EKG with atrial bigeminy. Cardiology was consulted and recommended increasing metoprolol to 100 from 50, and decreasing losartan to 25 from 50. # Diaphoresis The morning after admission, the patient had two episodes of diaphoresis. The first was gradual onset and non-exertional. The second was when opening his window. He had no chest pain, palpitations, dyspnea, lightheadedness, or nausea. Troponin was negative and EKG was stable. He was therefore kept an additional night for monitoring on telemetry, as it was felt that this may have been related to SVT discussed above. # New murmur IV/VII holosystolic murmur with obliteration of S2 loudest over base. TTE on last admission without any valvular disease. Plan for outpatient follow up with ___ and repeat TTE with bubble study to assess for VSD as outpatient. # Hypertension - Losartan and metoprolol as above # CAD s/p PCI - Continued home ASA 81, atorvastatin 80, and metoprolol (dosing as above) CAD with IMI ___ with 95% proximal circumflex lesion treated with DES. LAD with ostial ___ eccentric calcified lesion, mid and distal mild diffuse disease. D1 moderate size vessel with moderate diffuse disease. # OSA - Continued CPAP in house # BPH - Continued home tamsulosin and finasteride =================================== TRANSITIONAL ISSUES =================================== [ ] Medication change: metoprolol increased to 100 from 50, losartan decreased to 25 from 50. [ ] Continue to titrate metoprolol and losartan as outpatient. [ ] Repeat TTE with bubble study to assess for VSD as outpatient. [ ] ___ of ___ cardiac monitoring will be followed up Dr. ___ #CODE: Full #HCP: ___ ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ F h/o subdural hemorrhage on ___ (resolving on interval CT) now p/w worsening n/v, weakness. On ___, pt fell with head strike and CT imaging revealed an 8 mm R subdural hemorrhage w/ 5 mm of leftward shift. Interval CT since that time has shown improvement. Radiology showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST Q111 CT HEAD showed There is increased thickness of the right hemispheric subdural hematoma with increased effacement and mass effect of the right lateral ventricle and worsening midline shift to the left measuring up to 8 mm, previously 4 mm. No new hemorrhage. Continued evolution of the right subdural hematoma with overall decreased density. NOTIFICATION: The update findings were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 3:48 pm, 4 minutes after discovery of the findings. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Stable bilateral subdural hematomas as described above with stable 7 mm leftward midline shift. 2. No evidence of new hemorrhage or acute territorial infarction. 3. Mild luminal narrowing of the P1 segment of the left posterior cerebral artery. 4. Atherosclerotic vascular calcifications of the bilateral vertebral arteries with mild narrowing of the distal left V4 segment. 5. Atherosclerotic disease at the bilateral carotid bifurcations with approximately ___ right and 50-60% left internal carotid artery stenosis by NASCET criteria. 6. Mild narrowing at the origin of the left vertebral artery. 7. Nonspecific patchy parenchymal opacities within the right upper lung with small adjacent calcific foci measuring 0.8 x 0.8 cm and 1.1 x 0.7 cm. Recommend further evaluation with CT chest. RECOMMENDATION(S): Recommend CT chest to further evaluate nonspecific parenchymal opacities in the right upper lung. The patient was diagnosed with Nausea with vomiting, unspecified, Nontraumatic acute subdural hemorrhage. At the time of discharge, the patient had PRIMARY DIAGNOSIS: ================== Subdural hematoma Hypertension Orthostatic Hypotension SECONDARY DIAGNOSIS: ==================== Hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ F h/o subdural hemorrhage on ___ (resolving on interval CT) now p/w worsening n/v, weakness, found to be neurologically stable, and now being admitted to medicine for optimization of her BP management.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female who was traveling in ___, ___ on ___ at which time she suffered a mechanical fall and fell back and struck her head. A CT was completed in ___, which showed a small parafalcine hematoma, nondisplaced R occipital fracture. An overlying R occipital laceration was sutured with 2 sutures. She was admitted overnight there and discharged the next day after her CT was stable. She remained in ___ for 5 days and c/o of headache, nausea and vomiting but reports slow improvement of her symptoms. She flew Radiology showed PA and lateral chest compared to ___: Heart size top normal, unchanged. Lungs fully expanded and clear. Normal mediastinal and hilar silhouettes and pleural surfaces. Radiology showed 1. Mild-to-moderate degenerative changes involving the cervical spine with no evidence of malalignment or displaced fracture. However, as only two views of the cervical spine were acquired, if the mechanism of injury is concerning for cervical spine fracture, further imaging with a dedicated CT may be helpful. The patient was diagnosed with HYPOSMOLALITY/HYPONATREMIA, CL SKL BASE FX/MENIN HEM, UNSPECIFIED FALL. At the time of discharge, the patient had Primary diagnoses: Hyponatremia, SIADH Subdural hematoma Post-concussive symptoms. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of GERD, HTN with recent parafalcine hematoma in setting of mechanical fall, presenting with hyponatremia likely ___ SIADH. # Hyponatremia - Likely subacute. Not symptomatic. Improved slowly after nadir of 121. Her HA/LH have been present since her fall and are improving at time of discharge, and likely post-concussive. Likely was a mixed SIADH/volume picture on presentation, now only SIADH ___ SDH, CXR neg) after volume repletion. Renal was consulted, who recommended fluid restriction (1000 cc at discharge), salt tabs (stopped at discharge), and furosemide daily. Urine osms trend down. HCTZ was not restarted. She will have close PCP follow up and Na monitoring (___), as well as renal follow up. # Sinus sx: Treated with Flonase and saline spray. # Parafalcine Subdural Hematoma - stable per neurosurgery. Post-concussive symptoms continuously improved. Gait was stable. C-spine imaging was negative for gross injury. Restarted asa 81 per neurosurgery recommendations. Per neurosurgery, no indication for repeat imaging at this time. # Hypothyroidism: Continued levothyroxine. # HTN: Remained stable despite salt tabs. HCTZ was not restarted. Continued home lisinopril, increased dose to 40 mg to compensate for stopped HCTZ and new high salt diet. # GERD: Continued omeprazole. # HLD: Continued simvastatin. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of ESRD, Restrictive Lung Disease and COPD with 3L O2 requirement at baseline, presents from dialysis for fevers and cough. He developed a new cough yesterday night. This morning, he woke with abdominal pain but otherwise felt well. Developed rigors at dialysis. Afterwards, was very weak, somnolent per wife. ___ were called, but wife drove him to ___ as all of his care is here. Currently endorses headache, severe cough, mild dyspnea, periumbilical abdominal pain. No nausea, vomiting, chest pain, diarrhea. On arrival to the floor the patients vitals were 99.1 ___ 93 on 3L NC. The patient was not ___ acute distress and sitting up ___ bed. The patient reports that he feels much better than during his dialysis session. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative ___ detail. CHEST (AP AND LAT) showed Low lung volumes with bibasilar atelectasis. Radiology showed Soft tissue ulcer subjacent to the calcaneus without definite cortical destruction to suggest osteomyelitis. RECOMMENDATION(S): If there is continued clinical concern for osteomyelitis, consider MRI. CT abdomen and pelvis without IV contrast. showed 1. No acute abdominopelvic pathology. 2. The appendix remains dilated up to 10 mm, unchanged since ___, with no significant surrounding inflammatory changes to suggest acute appendicitis. 3. Severe atherosclerotic disease. NOTIFICATION: The findings were discussed in person by Dr. ___ with Dr. ___ on ___ at 8:10 ___, 5 minutes after discovery of the findings. The patient was diagnosed with Fever, unspecified, Syncope and collapse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with ESRD, COPD with 3L O2 requirement at baseline presents with chronic cough and new fevers,rigors and lethargy following dialysis. #Fever: On presentation to the ED, pt was afebrile, hemodynamically stable and sating 93% on 3L NC ___ no acute distress. Labs were notable for leukocytosis of 12.1, CRP 71, ESR 22. CXR showed bibasilar opacities consistent with atelectasis. On the floor, his max temp was 100.5 when he first arrived, but he defervesced without intervention and he remained afebrile throughout the rest of the admission. He was initially started on vanc/cefepime empirically for HCAP/bacteremia given comorbidities and significant health care exposure/HD. Blood cultures and sputum cultures had no growth. Noted to have R calcaneal ulcer that appeared to be at baseline with no purulent discharge or surrounding cellulitis. R foot x-ray showed no signs of osteomyelitis. Podiatry was consulted to evaluate, who had low suspicion for infection and recommended daily dressing changes and podiatry outpatient f/u. Wound culture grew flora and sparse growth of pseudomonas thought to be colonization. CT abd/pelv w/o IV contrast showed no acute abnormality. He was noted to have an intermittent systolic murmur thought to be a flow murmur, and given lack of blood culture growth no TTE was performed. Leukocytosis resolved. Antibiotics were discontinued given lack of culture growth without subsequent fever or symptoms, so fevers were attributed to likely viral illness. He was evaluated by ___ who recommended home ___. # ESRD Continued with hemodialysis on ___, ___ schedule. #DM: Managed on home regimen of glargine 60u BID as well as lispro sliding scale coverage. Noted to have an episode of fasting hypoglycemia with blood sugar ___ the ___ resulting ___ need to hold home glargine dose. Continued on home dose of glargine on discharge to be further modified as outpatient as needed. # CAD: continued ___, ___ (pt continues to take at home despite NSAID listed as allergy, resumed yesterday) metoprolol and atorvastatin . # Restrictive Lung Disease/COPD: Continued home oxygen of 3L and home inhalers. TRANSITIONAL ISSUES: -Noted to have episodes of morning hypoglycemia on current insulin regimen of glargine 60units BID, which per pt he and his wife modify based on his blood sugar levels. Please f/u appropriate insulin dosing as an outpatient. -To continue outpatient hemodialysis with ___ and ___ schedule (last HD on ___. -Discharged with home physical therapy. -Needs f/u ___ ___ clinic ___ days after discharge -Noted to have mild thrombocytopenia to 118 likely ___ setting of viral syndrome, please follow with repeat CBC as outpatient -Code: Full Code -Contact: ___ (Wife, HCP): ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female s/p pipeline embolization of left PCA aneurysm on ___ who was transferred from OSH with severe headache and N/V. The patient reports headache began yesterday morning and worsened throughout the day. ___ demonstrated thrombosis of aneurysm. Neurosurgery was consulted for further recommendations and evaluation. On exam the patient denies SOB, CP, visual disturbances. She endorsed photophobia, phonophobia and chills. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Pipeline stent embolization of a 1.4 x 1.3 cm left posterior cerebral artery aneurysm demonstrating internal clot and probable peripheral vascular wall enhancement, without definite evidence of residual flow to the aneurysm. Though in stent thrombosis cannot be excluded on the basis of this examination, there is no secondary evidence for in stent thrombosis. No edema is seen around the aneurysm. 2. No hemorrhage, infarct, or enhancing mass. RECOMMENDATION(S): If dedicated assessment for in stent thrombosis is desired, MRA of the head with and without gadolinium can be obtained, or alternatively CTA of the head. The patient was diagnosed with Headache, Dizziness and giddiness. At the time of discharge, the patient had Headache. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ is a ___ year old female S/P pipeline embolization of left PCA aneurysm with Dr. ___ on ___ who presents with severe headache and nausea and vomiting. A NCHCT was performed and demonstrated a thrombosed aneurysm. An MRI was performed to assess patency of the stent and did not show any occlusion, hemorrhage, or infarct. On HD 1 the patient continued with headache and was started on Dexamethasone for headache control. She continued on Brilinta and Aspirin. The patient remained neurologically and hemodynamically stable. Her nausea and headache improved. She was discharged home in stable condition on HD2.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with CLL on ibrutinib, CAD/HLD with NSTEMI in ___, nonischemic cardiomyopathy, CKD stage III, depression, presenting with presyncope and fall with humeral fracture, with elevated troponin in the emergency room. Radiology showed Acute impacted fracture through the surgical neck of the left humerus. CT HEAD W/O CONTRAST showed No acute intracranial process within limitations of this noncontrast study. No evidence of acute intracranial hemorrhage or acute fracture. CT C-SPINE W/O CONTRAST showed 1. No acute fracture or traumatic malalignment. 2. Redemonstration of 1.1 cm left thyroid lobe nodule. Please refer to recommendations section below for further instructions. RECOMMENDATION(S): 1.1 cmThyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. The patient was diagnosed with Unsp disp fx of surgical neck of left humerus, init, Other fall on same level, initial encounter. At the time of discharge, the patient had PRIMARY Fall Orthostatic hypotension L humerus fracture Urinary retention Hypertension Elevated troponin ___ SECONDARY Chronic lymphocytic leukemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>for Outpatient Providers: Mr ___ is a ___ male with CLL on ibrutinib, CAD/HLD with NSTEMI in ___, non-ischemic cardiomyopathy, CKD stage III, depression, presenting with presyncope and fall with humeral fracture, with elevated troponin, CK and ___. Patient's humeral fracture was treated non-operatively. He was fluid resuscitated to good effect, with normalization of Cr and CK. His troponin downtrended on repeat; CK-MB was normal, ECG was unremarkable and patient was asymptomatic throughout. Patient was followed by ___ and felt safe to go home with services.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of b/l breast cancers s/p mastectomies ___, ___, LUL NSCLC (___) s/p lobectomy and RUL NSCLC (___) s/p CK therapy, left atrial clot on ASA, p/w worsening sx of profound fatigue, shortness of breath and dizziness. She is unable to ambulate safely at home due to lightheadedness. Radiology showed Multifocal pneumonia in the right lung. Radiology showed No evidence of deep vein thrombosis in the right or left lower extremity. Radiology showed 1. Significant interval increase in the bulk of the tissue consolidation around the fiducial marker in the right upper lobe, the area of the patient's radiation-treated malignancy. Innumerable scattered right lung nodules are overall increased in size compared to the prior exam. Many of these nodules have become more confluent into larger nodules. 2. Interval increase in the size of the innumerable left lung nodules concerning for worsening metastatic foci. 3. Interval increase in the diffuse lymphadenopathy. Findings were placed in the critical results dashboard by Dr. ___ on the day of the exam. Radiology showed No evidence of metastatic disease. Radiology showed 1. No pneumothorax or acute superimposed pulmonary process detected compared with ___ at 11:59 a.m. 2. Sclerotic densities in the left proximal humerus and left glenoid, not fully evaluated. Radiology showed 1. Mild increase in size of soft tissue consolidation in the right mid lung. 2. New bilateral small pleural effusions, right greater than left. 3. Multiple pulmonary nodules bilaterally, some of which have slightly increased in size. 4. Subcarinal soft tissue consolidation is seen and there is an increase in attenuation on the adjacent right main bronchus. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS, HX-BRONCHOGENIC MALIGNAN, HX OF BREAST MALIGNANCY. The patient was treated with Bronchoscopy. At the time of discharge, the patient had Primary: lung cancer Secondary: paroxsysmal atrial fibrillation with rapid ventricular rate, anxiety. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a history of b/l breast cancers s/p mastectomies ___, ___, LUL NSCLC (___) s/p lobectomy and RUL NSCLC (___) s/p CK therapy, left atrial clot on ASA, h/o BPPV, p/w worsening sx of profound fatigue, shortness of breath and dizziness, found to have multifocal pneumonia and progression of lung cancer as well as newly diagnosed afib with RVR.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENTING ILLNESS: Ms. ___ is a ___ year old woman, with past history of ulcerative colitis s/p colectomy with ileal pouch anal anastomosis, c/b pouchitis (on Vedolizumab, budesonide), primary sclerosing cholangitis, GERD, Bipolar Disorder, and PTSD, who is presenting today for evaluation of abdominal pain. ULTRASOUND-GUIDED ASPIRATION showed Successful US-guided aspiration of a right lower quadrant cyst with 150 cc of clear straw colored fluid removed. PELVIS, NON-OBSTETRIC showed 4 cm right adnexal hypoechoic cystic structure, unclear, possibly representing previously drained right lower quadrant cyst. If further delineation is desired, MRI would provide further assessment. Small amount of free fluid may be minimally complex, difficult to discern whether truly free-fluid or if represents previously described residual peritoneal inclusion cyst. The patient was diagnosed with Right lower quadrant pain. The patient was treated with ___ Drainage of Peritoneal Cyst. At the time of discharge, the patient had PRIMARY DIAGNOSIS: 1. Peritoneal Inclusion Cyst s/p drainage. 2. Cystitis, complicated. SECONDARY DIAGNOSIS: 1. Ulcerative Colitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman, with past history of UC s/p colectomy with ileal pouch anal anastomosis, PSC, SBO, depression, GERD, Bipolar disorder, PTSD, now presenting with RLQ abdominal pain, urinary retention, concerning for symptomatic peritoneal cyst. . >> ACTIVE ISSUES: # Peritoneal Inclusion Cyst: # Abdominal Pain: Patient has had an inclusion peritoneal cyst for the past several months, as documented by MRE during past hospitalization. Patient over the past several months has been having increased waxing / waning abdominal pain, with urinary retention / incontinence. Patient had seen her outpatient providers, underwent transvaginal ultrasound demonstrating 11 cm peritoneal inclusion cyst, and because of persistence of symptoms came to the ED. Patient was evaluated by ___, with laboratory values normal, and underwent ___ guided aspiration and drainage of the cyst (150 cc of straw colored fluid) prior to arrival to medical floor. Upon arrival, patient was maintained on pain regimen of IV ketorolac and acetaminophen, and intermittent oxycodone as needed because of significant pain. Patient continued to have urinary retention, which she has had a history of in the past, and thought to be related to the cyst abutting the bladder. Patient underwent repeat ultrasound to identify if any obstructive from the cyst itself, which continued to show an adnexal cyst with ? septation, however no significant obstruction. Outpatient providers contacted for continuity, and alerted that patient may require MRI for further evaluation if needed. Prior to hospital discharge, patient's pain was controlled, and was given short supply of oxycodone upon discharge. Patient was instructed on use given concomitant benzodiazapenes, and able to teach back understanding of safety and use. Further, case was again discussed with ___ to determine the interval for repeat imaging, and was informed that likely will be based on symptoms on whether to re-image in the future and consider further drainages or more definitive type solutions in outpatient setting. . # Urinary Retention: Thought to be multifactorial. Patient has been evaluated several times in the outpatient setting, and has had to straight catheterize in the past. As above, repeat transvaginal ultrasound without any significant obstruction even post-drainage, and thought to be combination of irritation from the cysts, urinary tract infection likely from self catheterization, as well as medications. Patient was started on oxybutynin as previously been prescribed and well-tolerated, and monitored on technique for self catheterization. Patient did have supplies that last until end of ___, and therefore will be renewed in the outpatient setting by her urogynecologist as needed. Follow up appointment arranged, and patient started to have improvement in symptoms upon discharge. . # Urinary Tract Infection, complicated: Patient was found to have mixed culture upon arrival to the ED, however with straight catheterization started to note worsening dysuria and repeat urine culture with E. coli (despite normal U/A). Patient was started on TMP-SMX for course of 5 days given complicated, and will follow up sensitivities and make changes upon discharge. Patient reported dysuria starting to improve. . # Ulcerative Colitis: Patient now s/p colectomy s/p ileal pouch and anal anastomosis, with mild pouchitis documented previously Patient was continued on hydrocortisone PR, budesonide, hyocyamine, and vedolizumab to be continued in outpatient setting. . # Anxiety / PTSD / Depression: Patient on complex regimen including diazapem, clonazepam, and lorazepam as an outpatient. Patient does also have other sedating and activating medications including hydroxyzine (used for itching given PSC), as well as fiorcet and Adderall. PMP verified during hospital stay, prescribed by outpatient providers. Patient continued on modified regimen, and continued on discharge. Discussed extensively that with additional oxycodone, patient should refrain from driving or other activities given additional sedative effects. Would consider re-evaluating regimen to tailor in outpatient setting. . # History of Right Ankle Sprain: Patient was noted to be using a cane during hospital stay, has had previous workup including Xray and MRI. Patient to have f/u in outpatient setting. . # Primary Sclerosing Cholangitis: Patient was continued on cholesytramine, and ursodiol. . # Vitamin D Deficiency: Patient continued on home vitamin D. . # GERD: Patient continued on home famotidine. . # ADD: Adderall on hold given that patient only utilizes at work. An out of school letter was presented to patient upon discharge. . >> TRANSITIONAL ISSUES: # Peritoneal Cyst: Please continue to follow up with outpatient GYN and urogynecology. Patient may require serial imaging of this in the future to be determined as an outpatient by her outpatient GYN. ___ require MRI imaging based on ultrasound report. # Benzodiazpenes: Patient is on several different medications that are similar class (clonazepam, diazepam, and lorazepam), please continue to address as an outpatient. # Patient with urinary retention while hospitalized, likely secondary to cyst as above vs. pelvic floor dysfunction (previously evaluated with urodynamic studies). Started tamsulosin in house, discharged with instructions to straight cath PRN. Should f/u with urology vs. gyn as outpatient. # UTI: Found to have E. coli in urine s/p catheterization Urine culture sent and started on TMP-SMX (end date ___. Please follow up urine culture for sensitivities. # Ulcerative Colitis: Patient to have f/u with outpatient GI to continue vedolizumab as outpatient. # PMP: PMP was checked prior to discharge to verify prescribers. Discussed with patient to limit use of narcotics especially with use of benzodiazapenes in outpatient setting. # CODE STATUS: Full # CONTACT: ___, ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ M w/PMHx prostate CA s/p TURP on ___, LLE DVT on Coumadin at home (bridging with Lovenox s/p TURP), presented to the ED on POD#4 with decreased UOP, belly pain, hematuria, and vomiting. The foley was exchanged by urology and CBI was started. Patient went to the floor and became worse- hypotensive to SBP 70's, tachypneic, hypothermic to T ___, and lethargic, with belly looking more distended. He was moved to the FICU with plans to do a stat CT, but pt continued to decompensate- increasingly hypotensive and tachypenic. FAST exam showed free fluid, pt was intubated for stat OR; when resident went to place arterial line, felt the pulse get lost. CPR initiated, multiple rounds of epi, chest compressions continued while bedside ex lap was done. Large amount of blood tinged free fluid from bladder perforation. Was started on Levophed, fentanyl gtt, and sent to OR. ACS team called to assist. In OR, closed bladder injury. Placed suprapubic catheter as well as a foley, irrigating through the SPC and draining out foley. Abdomen was left open. Pt was stabilized post-operatively in the FICU and then transferred to the TICU. CHEST (PORTABLE AP) showed Stable cardiopulmonary findings. CHEST (PORTABLE AP) showed Stable exam Radiology showed Support lines and tubes are unchanged in position. Cardiomediastinal silhouette is within normal limits. There is again seen area consolidation and volume loss in the right upper lobe, stable. The rest of lung fields are grossly clear aside for a small right-sided pleural effusion. There are no pneumothoraces. Overall findings are unchanged. CHEST (PORTABLE AP) showed ET tube tip terminates right above the carinal. Right internal jugular line tip terminates at the level of lower SVC. NG tube tip is in the stomach. Heart size and mediastinum are stable. Right apical pleural thickening is unchanged. There is no appreciable pleural effusion. There is no pneumothorax. Radiology showed Endotracheal tube, feeding tube, and right IJ central line are unchanged position. There remains volume loss and collapse of the right upper lobe similar to prior. The rest of the lung fields are grossly clear. There are no pneumothoraces. There is again seen a known right sixth lateral rib lesion. CHEST (PORTABLE AP) showed Comparison to ___. Stable monitoring and support devices. Stable right upper lobe atelectasis and right lateral pleural thickening. Increasing retrocardiac atelectasis. No other changes are seen in the lung parenchyma. Stable borderline size of the heart. RENAL U.S. showed 1. Normal right renal ultrasound. Nonvisualized left kidney secondary to overlying bowel gas and bedside portable approach. 2. Suboptimal visualization of the urinary bladder, which appears collapsed around Foley catheter. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Right upper lobe has been collapsed since at least ___. Prior radiograph should be obtained to document whether this is a chronic finding or one which requires further investigation with chest CT. Heart size normal. Moderate left lower lobe atelectasis has worsened. Small right pleural effusion is likely. No left pleural effusion or pneumothorax. Cardiopulmonary support devices in standard placements. Radiology showed No evidence of retained sponge. NOTIFICATION: The findings were discussed with Dr. ___ by ___, M.D. on the telephone on ___ at 4:05 pm, less than 5 minutes after discovery of the findings. and by Dr. ___ with Dr. ___- 10 minutes after observation of these findings CR chest showed 1. Nasogastric tube coursing into the stomach. 2. Right upper lobe collapse stable, comparison to priors or investigation with chest CT recommended to exclude central obstruction. Radiology showed Low bilateral lung volumes and persisting right upper lobe atelectasis. Thickening of the right sixth lateral rib is again seen, suspicious for an underlying rib lesion. RENAL U.S. showed Moderate left hydronephrosis. CHEST (PORTABLE AP) showed -A right IJ central venous catheter terminates in the proximal right atrium. -Small right pleural effusion and right upper lobe atelectasis. -Thickening of the right lateral sixth rib Radiology showed There is a right IJ central line with the distal lead tip at the cavoatrial junction. There is again seen opacity within the right upper lobe and elevation the minor fissure consistent with atelectasis. Thickening of the right sixth lateral rib is again seen and demonstrated uptake on the prior bone scan suspicious for a rib lesion. The patient was diagnosed with Hematuria, unspecified. The patient was treated with Date: ___ Surgeon: ___, MD PROCEDURES: Exploratory laparotomy and superior abdominal closure. Date: ___ Surgeon: ___, MD PROCEDURE: Removal of VAC sponge and secondary abdominal closure. Date: ___ Surgeon: ___, MD PROCEDURE: Exploratory laparotomy with complex repair of bladder laceration, temporary abdominal wound closure. PRIOR ADMISSION: Date: ___ Surgeon: ___, MD PROCEDURE: Bipolar transurethral resection of prostate.. At the time of discharge, the patient had 1) Bladder perforation 2) abdominal compartment syndrome 3) Cardiac Arrest: cardiovascular collapse with return of circulation after CODE 4) Acute kidney injury on chronic kidney disease 5) generalized deconditioning 6) thrombosis, deep vein (pre-existing). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ male hx prostate cancer, DVT (LLE) POD4 from channel TURP, presented to the on ___ with hematuria. Had perforated bladder and developed abdominal compartment syndrome. Opened acutely at bedside after circulatory arrest, then taken to OR for exploration. Subsequently wound vac removed and abdominal wound closed by ACS on ___ and returned to ___. Extubated ___ ready for floor ___. Mr. ___ received ___ intravenous antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin, later converted to lovenox and restarted on Coumadin. With the eventual passage of flatus, diet was gradually advanced and the patient was transitioned from IV pain medication to oral pain medications. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. His drain was removed and his SPT care reinforced. Post-operative follow up appointments were arranged/discussed and the patient was discharged home with visiting nurse services to further assist the transition to home with OT, ___, Coumadin titration and waste elimination/care of the SPT. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx ___ dz on Remicaide, h/o MV endocarditis, gastritis, s/p cholecystectomy, s/p pancreatic stent & removal ___, presents with abdominal pain. Patient reports that he's been having crampy abdominal pain, diffuse but worst in the RLQ at the site of his ileocolonic resection, with accompanying nausea and loose, nonbloody diarrhea. This is reminiscent of his previous ___ flares. He had a fever to ___s an episode of emesis. There have been no sick contacts, no medication changes, no new or unusual foods, no alcohol intake. He made it through his Remicade treatment in the hope it would help, but his sx were not alleviated and continued to progress after, for which he went to the ED. In the ED, initial vitals were: 99.0 83 142/88 18 98%RA. Labs notable for: No leukocytosis, H/H ___ (at baseline), K 3.5 (Cr 1.0). Lipase 42. Lactate 1.3. CRP 2.2 (WNL). Imaging notable for: Nonspecific bowel gas pattern. Patient given: Morphine 5mg IV x2, Zofran 4mg IV x2, 1L NS. Vitals prior to transfer: 98.0 79 135/86 18 96% RA. On the floor, patient is awoken from sleep to recount the story above, continues to feel unwell with continued abdominal pain, but slightly better than when he came in. Review of systems: (+) Per HPI. Cardiac, respiratory, GU ROS negative. MR ___ showed Mild proctocolitis extending from the splenic flexure to the rectum. No active inflammation of the small bowel or complication of transmural disease. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the left PICC line was removed. The lung volumes are low. Normal size of the cardiac silhouette. Normal hilar and mediastinal structures. Mild elongation of the descending aorta. No pneumonia. No pneumothorax, no pleural effusions, no pulmonary edema. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. The patient was treated with Colonoscopy ___. At the time of discharge, the patient had Primary diagnosis: Abdominal pain/diarrhea Secondary diagnosis: ___ disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ hx ___ on Remicaide, gastritis, h/o MV endocarditis ___ picc line infection, s/p cholecystectomy, s/p prior pancreatic stent no longer present, s/p appendectomy, presents with acute abdominal pain and diarrhea. Febrile to 102 with elevation in CRP prompting initiation of cipro/flagyl with no further fevers. C. diff negative. Pain managed with morphine. MRE initially concerning for proctocolitis but colonoscopy negative for inflammation or signs of CMV infection. By discharge, tolerating PO with improved pain. Plan for outpatient GI follow-up.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old gentleman with h/o IVDU, recent SBO with ostomy, chronic back pain with multiple disk herniations and recent hx T12 osteomyelitis treated with ___ weeks vancomycin in ___, who is transferred to ___ from ___ with evidence of progression of osteomyelitis with associated with paraspinal abscesses. CT L-SPINE W/ CONTRAST showed 1. Vertebral osteomyelitis and diskitis at the thoracolumbar junction with complete destruction of the T12 vertebra, also involving the inferior endplate of T11 and the superior endplate of L1. 2. Perivertebral soft tissue thickening with probable epidural abscess. MRI may be performed to further evaluate. 3. Perivertebral abscesses extend into the upper psoas musculature, detailed above. These may be amenable to percutaneous drainage. 4. Opacities in the lower lungs likely represent atelectasis less likely pneumonia. Septal thickening suggests mild interstitial pulmonary edema. NOTIFICATION: Impression was discussed with Dr. ___ by Dr. ___ by phone at 12:30am on ___ approximately 45 minutes after discovery. MRI THORACIC AND LUMBAR PT6 MR SPINE showed 1. Discitis/osteomyelitis with abscess formation and resultant near-complete destruction of the T12 vertebral body and adjacent T11-12 and T12-L1 intervertebral discs. 2. Extension of infection posteriorly represents anterior epidural phlegmon. There is resultant compression and cord signal abnormality the extending from T11 to the conus, concerning for new/worsening cord compression. 3. No definite abscess or drainable fluid collection within the epidural space. 4. Extension of infection to involve the prevertebral and bilateral paraspinal musculature from T9-L2/3. In particular, multiloculated psoas abscesses are larger since prior measuring up to 3.6 cm, as above. 5. Possible focus of osteomyelitis in the posterior aspect of the T10 vertebral body, likely secondarily involved via extension from the adjacent paraspinal musculature. The T10-11 intervertebral disc is normal in appearance. CHEST (PRE-OP AP ONLY) showed Cardiomediastinal contours are normal. Nonspecific patchy and linear opacities at the right lung base are probably due to atelectasis although coexisting aspiration or developing infectious pneumonia are possible in the appropriate clinical settings. Known T12 lesion is seen to better detail on ___ dedicated spine MRI study. CT-guided drainage. showed Complete drainage of bilateral psoas abscesses yielding purulent fluid. No drainage catheters were left. Left T10 segmental artery arteriogram. Left T11 segmental artery arteriogram. Left T12 segmental artery arteriogram. Left L1 segmental artery arteriogram. Right T11 segmental artery arteriogram. Right L1 segmental artery arteriogram. Right common femoral artery arteriogram and Angio-Seal closure of right common femoral artery puncture site with 6 ___ Angio-Seal. ANESTHESIA: ANESTHESIA: MAC. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. TECHNIQUE: OPERATORS: Dr. ___ MD, PROCEDURE: The patient was brought to the angiography suite. IV sedation was given. Both groins were prepped and draped in a sterile fashion. Access was gained to the femoral artery using a Seldinger technique and a 5 vascular sheath was placed in the right common femoral artery. The above-mentioned spinal arteries were catheterized and AP filming was performed. This demonstrated that the artery of ___ did not originate from these vessels. FINDINGS: Left T10 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord. Left T11 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord. Left T12 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord Left L1 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord . Right T11 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord . Right L1 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord. Right common femoral artery arteriogram shows widely patent right common femoral artery. IMPRESSION: Artery of ___ was not visualized in the above segmental vessels showed Artery of ___ was not visualized in the above segmental vessels CT T-SPINE W/O CONTRAST Q321 CT SPINE showed 1. Near complete destruction of T12 vertebral body is again demonstrated, with a small sclerotic posterior vertebral body remnant and sclerosis extending into bilateral pedicles. Destruction of the T11 inferior endplate and L1 superior endplate is also again seen, marginated by irregular sclerosis. Unchanged kyphotic angulation centered at T12. 2. Abscess involving the T11-12 and T12-L1 disc spaces was better demonstrated on the ___ MRI. 3. Epidural phlegmon centered at T12 with associated spinal canal narrowing were also better demonstrated on the ___ MRI. 4. Previously noted bilateral psoas collections appear improved, but are not fully visualized and and not adequately evaluated in the absence of intravenous contrast. Left para-aortic lymphadenopathy is also not adequately reassessed. 5. Borderline enlarged paratracheal and subcarinal lymph and small bilateral pleural effusions may be reactive. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 10:22 AM, 5 minutes after discovery of the findings. CHEST (PRE-OP PA AND LAT) showed In comparison with the study of ___, there has been some decrease in the opacification at the right base, most likely due to atelectasis. No evidence of acute pneumonia or vascular congestion. Severe changes in the lower lobe thoracic region are consistent with known osteomyelitis. Intra op fluoroscopic images showed Intraoperative images during corpectomy of thoracic spine and placement of a biomechanical device. Please refer to the operative note for details of the procedure. Intra op fluoroscopy showed Intraoperative images were obtained during posterior fusion of lower thoracic and upper lumbar spine. CHEST (PORTABLE AP) showed Heart size and mediastinum are stable. Lungs are essentially clear with bibasal atelectasis. Left chest tube is in place. No pneumothorax is seen. CHEST (PORTABLE AP) showed Heart size and mediastinum are stable. Left chest tube is in place. Small left apical pneumothorax is present, not seen on previous examination. . No pleural effusion is noted. Right basal atelectasis is minimal. AP and lateral chest radiographs showed Interval removal of a left-sided chest tube with no change in the small left apical pneumothorax. CT T-SPINE W/O CONTRAST Q321 CT SPINE showed Expected postoperative appearance status post ___ corpectomy with extensive posterior spinal fusion. The left pedicle screw at T11 level projects over the left lateral recess. Clinical correlation recommended. There is no evidence of hardware failure and the spinal alignment appears anatomic. However, evaluation of the adjacent soft tissues is severely limited secondary to extensive hardware-related streak artifact. CHEST (PA AND LAT) showed Persistent, small left apical pneumothorax. DX CHEST PORTABLE PICC LINE PLACEMENT showed New right-sided PICC line. The course of the line is unremarkable, the tip of the line. Projects over the cavoatrial junction. No complications, notably no pneumothorax. The stomach remains overinflated. And could be decompressed by insertion of a nasogastric tube. The patient was diagnosed with Osteomyelitis of vertebra, thoracic region. The patient was treated with ___: Bilateral psoas muscle abscess drainage ___: Diagnostic Spinal Angiogram ___: Corpectomy T11/12 and PSF T9 to L2, chest tube placement. At the time of discharge, the patient had T12 osteomyelitis Anemia Acute on chronic pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male with h/o IVDU, recent SBO with ostomy in ___ ___, chronic back pain with multiple disk herniations and recent hx T12 osteomyelitis treated with ___ weeks vancomycin in ___ with evidence of progression of osteomyelitis with associated with paraspinal asbcesses. He was transferred to the ED on the day of admission, ___ ___ for spine surgery evaluation. On ___, the patient underwent a MRI for possible ___ drainage of psoas abscess. On ___, the patient underwent a bilateral psoas muscle abscess drainage. On ___, the patient was transferred from medicine to neurosurgery. On ___, the patient underwent an ECHO which was negative for endocarditis. He underwent a spinal diagnostic angiogram later that day. On ___, the patient remained neurologically stable on examination. His Vanc trough was 22 and his Vancomycin was decreased to 1g every 12 hours. He noted new onset bilateral anterior thigh radiculopathy. He was started on Gabapentin BID dosing. ___: Neuro exam stable. To start Gabapentin TID dosing today. HCT downtrending to 23.7/7.2; Vanco level 18.6 ___: Transfused for H/H 6.___. Sent anemia labs. Re-consulted Medicine. ___ discontinued as medicine thinks there may be an internal bleed. ___: vanco 16.3, added bowel meds ___: 1 units packed cells, consent for surgery, t spine ct no contrast ___: OR, chest tube placed intraop ___: Chest tube to waterseal by Thoracics, CXR at 1000 with small PTX. AM CXR ordered per Thoracic. ___: Micro called- growing rare staph aureus in the vertebral body sent from OR on ___. Dressing removed, drain kept in place. Hct drop 3 pts today. ___: Patient is doing well and continues to work with ___. Pt was evaluated by CPS today who recommended stopping the PCA and starting him on Oxycodone 20mg PO Q 4 PRN pain and continuing his Oxycontin. His Hgb and HCT was 7.1 and 22.4, however he remains asymptomatic and we will continue to trend his levels. His JP put out 40cc overnight and was removed. ___: The patient's hemoglobin was 7.6, though he remained asymptomatic. His pain was well controlled. The vancomycin dosing was increased to 1250 q12 for trough 11.8 ___: His hemoglobin was 7.3, and again was asymptomatic. His back brace was available at bedside. ___: The hemoblgobin was up to 8.1, and hematocrit up to 25.2. An order was placed for a PICC line to be placed for longterm vancomycin treatment. The screening process for rehab was initiated. On ___ PICC line was placed. He was screened for rehab placement. His Hct/Hgb was stable. On ___ Patient remained stable awaiting insurance authorization for discharge to rehab. Home medications adderal, gabapentin and klonopin were restarted. On ___, the patient remained hemodynamically and neurologically stable with no overnight events. The patient was transitioned to PO pain medication. His insurance was accepted for rehab, and he is stable and ready for discharge to rehab for ongoing physical therapy. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male s/p CABGx3 (LIMA-ALD, SVG-OM, SVG-Ramus) on ___. Overall he tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He developed slow afib post-operatively but lopressor was initially held due to continued hypotension. On POD#2, he received 2 units of PRBC for a hematocrit of 17. Stat bedside echo was unremarkable. Plavix was resumed for his history of DES placed in ___. He transferred to the telemetry floor for further recovery. He was started on coumadin for persistent atrial fibrillation. He continued to have paroxysmal atrial fibrillation and Amiodarone was initiated. His Hct remained low but stable. He was discharged to home on ___. He was doing well initially except for some persistent SOB with minimal exertion and stairs. Over the past few nights, he experienced PND, awakening several times per night. Otherwise he has felt well - no CP, palitations, pain well controlled. He presented to PCP for ___ routine follow up and was unable to lie flat for an exam. His PCP sent him to the ED for further evaluation. Radiology showed Increased size of left pleural effusion which is now large with associated left basilar atelectasis. Trace right pleural effusion. Radiology showed Stable large left pleural effusion with overlying atelectasis. Possible trace right pleural effusion. The patient was diagnosed with SHORTNESS OF BREATH, HYPERTENSION NOS, DIABETES UNCOMPL ADULT. The patient was treated with ___ left thoracentesis. At the time of discharge, the patient had s/p Left thoracentesis ___ s/p Urgent coronary artery bypass graft x3: ___ Left internal mammary artery to left anterior descending artery and saphenous vein graft to distal circumflex and ramus arteries Past Medical History: MI ___, angioplasty 6 months later DMII dyslipidemia Hypertension BPH Past Surgical History: herniorrhaphy Past Cardiac Procedures: angioplasty ___ DES to Cx ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient had a large left effusion on chest xray. His INR on admission was 2.4 and his coumadin was held. He was diuresed but there was no change in the effusion. His INR came down to 1.7 and he had a left thoracentesis and 2 liters of serosanguineous drainage was obtained. His breathing improved greatly. He remained in sinus rhythm throughout this hospitalization and his coumadin was discontinued. His blood sugars had been high and his metformin and glucophage were increased. He was discharged to home in stable condition with follow up appointments.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male well known to the Transplant Surgery service who underwent a DDLT in ___ for HCV cirrhosis and HCC and has a had a prolonged postoperative course complicated by hepatic artery thrombosis with hepatic lobe necrosis, early mild to moderate cellular rejection, infected biloma with recurrent bacteremia, multiple intraabdominal collections, several ___ interventions, and a right iliacus hematoma causing RLE compression paralysis, resolved with ___ drainage and multiple hospitalization. He was most recently admitted ___ for failure to thrive and acute SDH after several falls at home. He was also noted to have increased fluid collections and underwent ___ drainage exchange of existing CT ABDOMEN W/CONTRAST showed 1. There has been near resolution of fluid surrounding 2 percutaneous drains near the gallbladder fossa. 2. Interval decrease in size of hypoattenuating lesions in segment 8 and segment 6 of the liver. The lesion in segment 6 has also had interval resolution of internal gas. 3. Trace fluid remains near previously drained fluid collection adjacent to the lateral inferior spleen. 4. There has been decrease in size of more centrally located fluid collection in the spleen. 5. No new O focal fluid collections. 6. Unchanged splenomegaly. CHEST (PORTABLE AP) showed The right PICC line terminates within the upper SVC. Radiology showed Drain exchanges as above. Radiology showed Technically successful plasty in the region of the hepaticojejunostomy. Successful exchange of existing percutaneous transhepatic biliary anchor drain with new 10 ___ internal-external biliary drainage catheters. The patient was diagnosed with Hypokalemia, Type 2 diabetes mellitus without complications. The patient was treated with ___: 1. Cholangiogram through existing right percutaneous transhepatic biliary drainage access. 2. Exchange of the existing right percutaneous transhepatic biliary drainage catheter with a new 10 ___ anchor catheter. 3. Sinogram through existing left drain 4. Exchange of left drain to a 10 ___ APD L . ___ 1. Scout radiograph image of the indwelling drains 2. Antegrade cholangiogram through the indwelling anchor drain. 3. Drain check injection through the existing percutaneous drain in the hepatic collection 4. Over the wire Pull-back cholangiogram via the right PTBD 5. Balloon angioplasty of the hepaticojejunostomy using a 6 mm Conquest balloon 6. Post HJ plasty antegrade cholangiogram 7. New right 10 ___ biliary internal-external drainage catheter.. At the time of discharge, the patient had Hyperkalemia History of liver transplant DM h/o right iliacus hematoma with right femoral nerve compression Right leg numbness/pain/weakness Neutropenia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male h/o deceased donor liver transplant ___ for HCV cirrhosis and HCC with prolonged postoperative course complicated by hepatic artery thrombosis with hepatic lobe necrosis, early mild to moderate cellular rejection, infected biloma with recurrent bacteremia, multiple intraabdominal collections, several ___ interventions, and a right iliacus hematoma causing RLE compression paralysis, resolved with ___ drainage and multiple hospitalization. He was most recently admitted ___ for failure to thrive and scute SDH after several falls at home. He was also noted to have increased fluid collections and underwent ___ drainage exchange of existing left hepatic lobe drain with ___ APDL. He was continued on pre-admission Daptomycin and Cefepime. . He presented for CT scan on ___ to evaluate known collections. At the appointment, potassium was elevated to 7.3. He was sent to the ED for hyperkalemia management. In the ED he received calcium gluconate, insulin/dextrose, sodium bicarb, and 20 IV Lasix. Repeat K was 5.3. He reported eating a diet rich in tomatoes/red sauce and potatoes over the last few days. Bactrim was stopped and he was put on a low K diet. He was continually monitored on telemetry and there were no abnormalities. K on repeat checks was 5.3, 5.0 and 5.0. . On ___ he underwent Cholangiogram through existing right percutaneous transhepatic biliary drainage access, Exchange of the existing right percutaneous transhepatic biliary drainage catheter with a new 10 ___ anchor catheter. Sinogram through existing left drain and Exchange of left drain to a 10 ___ APD He remained afebrile after this procedure . On ___ he went back to ___ for Scout radiograph image of the indwelling drains, Antegrade cholangiogram through the indwelling anchor drain, Drain check injection through the existing percutaneous drain in the hepatic collection. Over the wire Pull-back cholangiogram via the right PTBD, Balloon angioplasty of the hepaticojejunostomy using a 6 mm Conquest balloon with Post HJ plasty antegrade cholangiogram and new right 10 ___ biliary internal-external drainage catheter. . The patient was also seen by ___ while inpatient. ___ recommended home for discharge after a right ___ brace was obtained that he was able to apply himself. . DM was also monitored and he was continued on Lantus and standing meal time doses of Humalog with sliding scale. Glucoses averaged 100s to 200. . LFTs were stable. Immunosuppression consisted on Prednisone 5mg daily and Tacrolimus dosed per trough levels. . Immuknow was sent on ___, result pending at time of discharge . Patient became increasingly neutropenic during the admission. He received 2 doses of 300 mcg each of filgrastim with good recovery of white count and the ANC. . Transitional issues: f/u weekly transplant labs f/u with ___ ... ID.... transplant surgery</s>